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MANIC - DEPRESSIVE
INSANITY

AND

PARANOIA

Professor EMIL KRAEPELIN of Munich

TRANSLATEU BY

R. MARY BARCLAY, M.A., M.B.

From the Eighth German Edition of the " Text-Book of Psychiatry,
vols. lit. and iv.

EDITED BY

GEORGE M. ROBERTSOxN, M.D., F.R.C.P. (Edin.)

Professor of Psychiatry in the University of Edinburgh
and Physician to the Royal Asylum, Morning-side

to '^ ■^'^

EDINBURGH

E. & S. LIVINGSTONE

17 TEVIOT PLACE

1921

EDITOR'S PREFACE

The conception of Manic-Depressive Insanity as a definite form
3f mental disorder, various and antithetical though some of the
symptoms appear to be in different attacks and even in different
phases of the same attack, is one of Professor Kraepelin's most
Iiappy generalisations. Naturally, so startling a departure from
Dlder classifications was not at first accepted by all, though the
w^ay for recognition had been paved by the differentiation and
description of Folic Circulaire by French alienists, but further
xperience and familiarity with the idea led to the almost
universal admission of its truth. It is to Professor KrsepeUn's
credit that he also has developed his own views with increase
of knowledge, for he now includes what is often called
Involution Melancholia in this group, his failure to do so in
his original statement having been regarded by many as a
mistake.

Professor Kraepelin's account of Manic-Depressive In-
sanity, conjoined with that of Dementia Praecox, forms
probably his greatest achievement in psychiatry. The last
word, however, has not been said on the subject. Many
important problems have yet to be solved. Professor KraepeUn,
for example, apparently takes the physiological view that the
essential feature of Mania is excitement and excitabiUty, and
of Depression or Melancholia, inhibition and depression of
function. This leads to difficulty when Anxious or Excited
Melancholia comes to be dealt with, which is avoided if the
psychological view be adopted, that the symptoms in Mania
are but morbid developments of the feelings of elation or anger,
and in Melancholia of depression and despair, or of fear and
anxiety, a species of caricature of these feelings as Maudsley
has suggested. Kraepelin's group of mixed states of Mania and
Depression, into which he places Anxious Melancholia, would
be reserved under the above hypothesis for those cases'

vi MANIC-DEPRESSIVE ENSANITV

comparatively few in number, occurring usually after several
attacks, and suffering probably from some degree of dis-
integration of function, in which the feelings get strangely
mixed up, as well as the secondary or associated symptoms.
This point is mentioned to give but one illustration of the
suggestive and stimulating nature of Kraepelin's work.

The latter part of the book is devoted to an account of
Paranoia, which title is employed in the narrowest sense and is
restricted in application to those forms, which are very often
described as " true " or non-hallucinatory Paranoia. The more
numerous allied and hallucinatory forms are mainly grouped
by Kraepehn under the title Paraphrenia, though some may
be included under Paranoid Dementia Praecox, to which dis-
order its relationship is undoubtedly very close. Further, it
may be added that as true Paranoia has also affinities to some
varieties of Mania, all these forms of insanity seem to merge
into one another at their so-called boundaries or limits, as do
the colours of the spectrum, though the fully developed and
typical forms are as distinct from one another and as
recognisable as the primary colours.

The medical profession is under a debt of gratitude to Dr
Mary Barclay for her faithful rendering into English of these
classical studies. She has now completed the translation of
Professor Kraepelin's careful descriptions of those forms of
mental disorder which are commonly known as The Psychoses,
namely. Dementia Praecox, Paraphrenia, Manic-Depressive
Insanity, and Paranoia. These disorders form a definite group
and provide the most effective illustrations of Professor
Kraepehn's accurate methods of analysing and investigating
mental disease. His orderly descriptions will be found of
great value to the medical officers of our mental hospitals, and
to all engaged in the study of clinical psychiatry, particularly
to those reading for a Diploma in Psychological Medicine.

GEORGE M. ROBERTSON.

University of Edinburgh,
December 1920.

TRANSLATOR'S PREFACE

In translating Manic- Depressive Insanity and Paranoia, I have,
as in Dementia PrcECox and Paraphrenia, tried to reproduce
the original as literally as possible. Professor Robertson
suggested that I should translate these two sections in order
to complete the psychoses, and I am grateful to him for the
suggestion, as Professor Kraepelin treats his subjects in such
a way that, even although one may not always agree with
him, one is bound to admit that he shows most exhaustively
what can be done in the examination of patients, and in the
classification, of symptoms singly and in groups. I hope that
the translation may lead to further detailed study of those
diseases among English-speaking peoples.

I have again to express my thanks to Dr Walker for
kindly reading the proofs.

R. MARY BARCLAY.

London, November igso.

CONTENTS

MANIC-DEPRESSIVE INSANITY

CHAPTER

I. Definition

PAGE
I

II. Psychic Symptoms —

Perception ....

Attention , . . .

Consciousness

Memory ....

Retention (pseudo-memories)

Hallucinations

Association (flight of ideas, inhibition of thought)

Mental efficiency

Delusions ....

Disposition ....

Volition (pressure of activity, pressure of speech, in

hibition, indecision, anxious excitement)
Experiments with the writing-balance

13
17

26
40

III. Bodily Symptoms —

Sleep ....

Nourishment .

Body-weight .

Metabolism

Blood-picture . ...

Circulation (blood-pressure)

Respiration

Nervous disorders

Hysterical symptoms (seizures)

44
44
45
48

49
SO
52
52
52

IV. Manic States —

Hypomania
Acute mania .
Delusional forms

54
61
68

CONTENTS

Delirious forms

Course

Duration

PAGE

72
73

V. Depressive States —

Melancholia simplex .....

Stupor ......

Melancholia gravis .....

Paranoid melancholia ....

Fantastic melancholia ....

Delirious melancholia ....

Course

Duration ......

VI. Mixed States —

Definition

Schematic representation

lOI

Depressive mania

103

Excited depression .

104

Mania with poverty of thought

104

Manic stupor .

106

Depression with flight of ideas

107

Inhibited mania

109

Partial inhibition

109

Acute delirious mania

III

Grumbling mania

III

Partial mixtures

112

Course

VII. Fundamental States —

Depressive temperament
Manic temperament .
Irritable temperament
Cyclothymic temperament

118
125
130

VIII. Frequency of the Individual Forms. General
Course —

Colouring of the individual attacks
Duration of the attacks and intervals
Examples ot various courses
Behaviour in the intervals .
Transitions . . . -

133
137
139
J 49
150

l^UJNiliiNlb

CHAPTER

PAGE

IX. Prognosis —

Frequency of attacks ....

159

Cyclothymia ......

160

Chronic melancholia and mania

161

Arteriosclerotic and senile dementia

163

Death .......

164

X. Causes —

Hereditary taint ...... 165

Ag-e (frequency and colouring of the attacks) . . 167

Sex ........ 174

Personal peculiarity ...... 177

Physical causes (alcohol, syphilis, head injuries, bodily

illnesses, work of reproduction) . . .177

Psychic causes . . . . . .179

Nature of the disease (vasomotor disorders, metabolic dis-
orders, auto-intoxication, developmental inhibitions) 181

XI. Delimitation —

Periodic forms

185

Cases of only one attack

189

Melancholia ....

190

Mixed states ....

191

"Chronic mania"

192

Periodic neurasthenia and paranoia

192

Cyclothymia ....

193

Alternating- forms

193

Dementia praicox

194

Delusional forms

194

XII. Diagnosis-

Neurasthenia .

195,

Moral insanity

196

Querulant delusion

196

Compulsion neurosis .

197

Paralysis

197

Cerebral Syphilis

198

Arteriosclerosis

198

Amentia (confusional

3r delirious insanity)

199

Hysteria

199

Psychogenic states of

depression .

199

Imbecility

200

CONTENTS

CHAPTER

XIII. Treatment —

Suppression of attacks (artificial abortion) . . 202

Manic excitement ...... 203

States of depression (suicidal tendency, discharge) 204

PARANOIA

I. Introduction-

History of the conception of paranoia
Paranoia and paranoid diseases
Definition of the conception
Views of the French psychiatrists .

207
210
212
213

II. Clinical Picture —

Visions ......

215

Pseudo-memories .....

216

Delusion of reference ....

217

Delusion of injury .

220

Delusion of grandeur ....

220

Systematization (mild and abortive forms)

221

Mood .......

222

Activity *......

223

Conduct ......

223

Bodily Symptoms ....

224

III. Clinical P'orms —

Delusion of persecution
Delusion of jealousy .
Delusion of invention
Delusion of descent .
Delusion of prophets and saints
Delusion of eroticism

225
229
232

235
238

245

IV. Course and Issue

250

V. Frequency, Causes, Character of the Disease-

Abnormal development or morbid process

254

CONTENTS

CHAPTER

VI. Delimitation —

Curable forms
Abortive paranoia
Dementia prascox
Paraphrenia .
Psychopathy .
Manic-depressive insanity
Paranoid personalities

XIII

PAGE

266
266
266
266
267
267
268

VII. Diagnosis, Treatment —

Schizophrenia .

Paraphrenia

Manic-depressive insanity

Hypomania

Liars and swindlers .

Treatment

273
274

275
275
276
276

LIST OF ILLUSTRATIONS

no.

1. Perception and retention in normal and in manic

individuals .

2. Caricature seen in hallucination

3. Manic patients

4. Manic patient with numerous plaits

5. Ornamented manic patient

6. Changing^ positions of a manic patient

7. Frequency of clang associations in normal and in

manic individuals

8. Simple finger movement in depression

9. Pressure curve in writing in manic-depressive

insanity .....

10. Body-weight during a manic attack .

11. Body-weight in mania of long continuance .

12. Large fluctuations of body-weight in mania .

13. Body-weight during a combined attack

14. Body-weight in depression

15. Body- weight in depression with protracted course

16. Blood pressure, pulse rate and body-weight in mania

17. Depressive stupor

18. The same

19. Depression

20. Comparison in mixed states of manic-depressive

insanity

21. Manic stupor .
22-39. Diagrams of the course

22. Periodic depression

23. Depression in youth and at the age of involution

24. Frequent states of depression

25. Periodic states of depression after a few manic

attacks

26. Chronic depression

27. Periodic mania

28. Relapsing mania

29.

SC-
SI

S2-

33-
34-
35-
S6.
37-
S8-

39-

40.
41.

42.

43-
44.

45-

46.
47-

48.
49.

LIST OF ILLUSTRATIONS

Relapsing mania with a few states of depression
Periodic mania with issue in circular insanity-
Chronic mania
Folie k double forme .
Folie circulaire

Circular attacks with a long- interval
Circular insanity with depression in youth
Circular insanity with prodromal delirious attacks
Depression with transition to circular insanity
Depression of long continuance with transition to
mania ......

Irregular circular insanity almost filling the whole

life .
Hypomania ....
Mania .....
Percentage relationship of clang associations in

mania and depression
Number of right and wrong perceptions in th(

transition from depression to mania
Body-weight in two double attacks of manic

depressive insanity
Distribution of first attacks of manic depressive

insanity (903 cases) at different ages
Colouring of the attacks at different ages
Share of the sexes in manic-depressive insanity

(first attacks) at different ages
Distribution of 1704 attacks of manic-depressive

insanity at different ages .
Paranoiac title-page .

PAGE

H3
144

144
145

H5
146
146
147
147

148

148
154
155

157

158

168
169

172

17s

246

SPECIMENS OF WRITING

1. Writing in mania

2. Manic scribbling

3. Excitement after a dispute with a nurse

4. Depression ....

35
67

156
156

Manic-Depressive Insanity

CHAPTER I.

DEFINITION.

Manic-depressive insanity,^ as it is to be described in this
section, includes on the one hand the whole domain of so-
called periodic and circular insanity, on the other hand simple
mania, the greater part of the morbid states termed melan-
cholia and also a not inconsiderable number of cases of
amentia} Lastly, we include here certain slight and slightest
colourings of mood, some of them periodic, some of them con-
tinously morbid, which on the one hand are to be regarded
as the rudiment of more severe disorders, on the other hand
pass over without sharp boundary into the domain of personal
predisposition. In the course of the years I have become
more and more convinced that all the above-mentioned states
only represent manifestations of a single morbid process. It
is certainly possible that later a series of subordinate forms
may be described, or even individual small groups again
entirely separated off. But if this happens, then according

1 Kirn, Die periodischen Psy chosen, 1878 ; Mendel, Die Manie, eine
Monographic, 1881 ; Pick, Circulares Irresein, Eulenburgs Realenzyklo-
padie ; Hoche, Uber die leichteren Formen des periodischen Irreseins, 1897 ;
Hecker, Zeitschr. f. praktische Arzte, 1898, i ; Pilcz, Die periodischen
Geistesstorungen, 1901 ; Thalbitzer, Den manio-depressive Psykose, Stem-
mingssindsygdom, 1902 ; Seiffer, Deutsche Khnik. 1904 ; Deny et CamuF,
La psychose maniaque-depressive, 1907 ; Antheaume, les psychoses
periodique, 1907 ; Binet et Simon, L'Annee psychologique, xvi., 164 ;
Pierre-Kahn, La cyclothymia, 1909 ; Remond et Voivenel, Annales medico-
psychol., 1910, 2, 353; Thomsen, Medizinische Klinik, 1910, 45 und 46;
Stransky, Das manisch-depressive Irresein, 191 1 (Aschaffenburgs Hand-
buch) ; Homburger, Zeitschr. f. d. ges. Neurol, u. Psych., Refer. XL, Q-io
(Literatur) .

'^ Confusional or delirious insanity.

2 MANIC-DEPRESSIVE INSANITY

to my view those symptoms will most certainly not be
authoritative, which hitherto have usually been placed in the
foreground.

What has brought me to this position is first the ex-
perience that notwithstanding manifold external differ(^nces
certain common fundamental features yet recur in all the
morbid states mentioned. Along with changing symptoms,
which may appear temporarily or may be completely absent,
we meet in all forms of manic-depressive insanity a quite
definite, narrow group of disorders, though certainly of very
varied character and composition. Without any one of
them being absolute^ characteristic of the malady, still in
assoQJation they impress a uniform stamp on all the multi-
form clinical states. If one is conversant with them, one
will in the great majority of cases be able to conclude in re-
gard to any one of them that it belongs to the large group of
forms of manic-depressive insanity by the peculiarity of the
condition, and thus to gain a series of fixed points for the
special clinical and prognostic significance of the case. Even
a small part of the course of the disease usually enables us to
arrive at this decision, just as in paralysis or dementia pra^cox
the general psychic change often enough makes possible the
diagnosis of the fundamental malady in its most different
phases.

Of perhaps still greater significance than the classification
of states by definite fundamental disorders is the experience
that all the morbid forms brought together here as a clinical
entity, not only pass over the one into the other without
recognisable boundaries, but that they may even replace each
other in otie and the same case. On the one side, as will be
later discussed more in detail, it is fundamentally and
practically quite impossible to keep apart in any consistent
way simple, periodic and circular cases ; everywhere there
are gradual transitions. But on the other side we see in the
same patient not only mania and melancholia, but also states
of the most profound confusion and perplexity, also well
developed delusions, and lastly, the slightest fluctuations of
mood alternating with each other. Moreover, permanent,
one-sided colourings of mood very commonly form the back-
ground on which fully developed circumscribed attacks of
manic-depressive insanity develop.

A further common bond which embraces all the morbid
types brought together here and makes the keeping of them
apart practically almost meaningless, is their uniform proii-

DEFINITION 3

nosis. There are indeed slight and severe attacks which may
be of long or short duration, but they alternate irregularly in
the same case. This difference is therefore of no use for the
delimitation of different diseases. A grouping according to
the frequency of the attacks might much rather be con-
sidered, which naturally would be extremely welcome to the
physician. It appears, however, that here also we have not
to do with fundamental differences, since in spite of certain
general rules it has not been possible to separate out definite
types from this point of view. On the contrary the uni-
versal experience is striking, that the attacks of manic-
depressive insanity within the delimitation attempted here
never lead to profound dementia, not even when they con-
tinue throughout life almost without interruption. Usually
all morbid manifestations completely disappear ; but where
that is exceptionally not the case, only a rather slight,
peculiar psychic weakness develops, which is just as common
to the types here taken together as it is different from
dementias in diseases of other kinds. .

As a last support for the view here represented of the
unity of manic-depressive insanity the circumstance may be
adduced, that the various forms which it comprehends may
also apparently mutually replace one another in heredity.
In members of the same family we frequently enough find
side by side pronounced periodic or circular cases, occasion-
ally isolated states of ill temper or confusion, lastly very
slight, regular fluctuations of mood or permanent con-
spicuous colouration of disposition. From whatever point
of view accordingly the manic-depressive morbid forms may
be regarded, from that of aetiology or of clinical phenomena,
the course or the issue — it is evident everywhere that here
points of agreement exist, which make it possible to regard
our domain as a unity and to delimit it from all the other
morbid types hitherto discussed. Further experience must
show whether and in what directions in this extensive domain
smaller sub-groups can be separated from one another.

In the first place the difference of the states which usually
make up the disease, presents itself as the most favourable
ground of classification. As a rule the disease runs its
course in isolated attacks more or less sharply defined from
each other or from health, which are either like or unlike, or
even very frequently are perfect antithesis. ^ Accordingly we
distinguish first of all manic states with the essential morbid
"symptoms of flight of ideas, exalted mood, and pressure of

4 MANIC-DEPRESSIVE INSANITY

activity, and melancholia or degressive states with sadjor.
anxious moodiness and also sluggishness of thought and
---actiPRr]p^he5e^twe-^ppose3~p1mse of tlie'clinical state have
(given 'fhe disease its name. But besides them we observe
also clinical " mixed forms," in which the phenomena of
mania and melancholia are combined with each other, so
that states arise, which indeed are composed of the same
morbid symptoms as these, but cannot without coercion be
classified either with the one or with the other.

CHAPTER II.
PSYCHIC SYMPTOMS.

Before we proceed, however, to the description of the mani-
fold states which make up the whole clinical course, it will be
convenient to obtain a general view of the individual psychic
disorders peculiar to manic-depressive insanity.

The Perception of external impressions is in mania in-
variably encroached upon, sometimes even very considerably.
Only in very slight forms of the malady do we find values
which correspond perhaps to the lower values of normal
individuals, but which are decidedly below the average.

Oesundc. richtig ^
falsch I I

Maniscbe. richlig H|
Ulsch O

ne in " o" 5"

Jormal 1.49+0.77 1.48+0.94
lanic 1.19+1.33 ^•15+1-54

40"
1.63+0.94
1.19 + 1.7S

Fig. I.

-Number of letters perceived tachistoscopically and re-
membered by normal and manic individuals.

Paton, in experiments on sensation in manic patients, obtained
strikingly poor results. Wolfskehl, who investigated tachi-
stoscopic perception of series of letters, found that the
patients yielded on the average about one quarter fewer
correct results than the normal controls. The comparatively
large number of mistakes made was noticeable, which, how-
ever, was not nearly so large as in dementia praecox, biit yet
was larger than in normal individuals. This ratio is 're-
presented by the first vertical of Fig. i, in which the correct

6 MANIC-DEPRESSIVE INSANITY

and the wrong results of normal individuals and of manic
patients are compared. The patients apparently perceive
carelessly and inaccurately ; but on the other hand isolated
experiences lead to the belief that their pressure of speech
readily tempts them to make statements when they have
really seen nothing. Frequently the severity of the dis-
order of perception is in remarkable contrast to the in-
significance of the clinical manifestations.

Extraordinary Distractibility of Attention certainly
plays an essential part in defective perception. The
patients gradually lose the capacity for the choice and
arrangement of impressions ; each striking sense-stimulus
obtrudes itself on them with a certain force, so that they
usually attend to it at once. Accordingly, if their attention
can for the most part be quickly attracted by the exhibition
of objects or by the calUng out of words, yet it digresses
again with uncommon case to any fresh stimulus. The
picture of their surroundings and of events remains, therefore,
for them more disconnected and more incomplete than it
would be, if it suffered merely from encroachment on the
process of perception.

Perception frequently appears to be less severely dis-
ordered in depressive states ; the tendency to mistaken
readings especially is in general absent. Franz and Hamil-
ton found in inhibited patients that the threshold values
were raised for touch, pressure, and pain stimuU. Further,
in severe cases, according to the often very characteristic
utterances of the patients, a slowing and sluggishness of
recognition is apparently invariably found, which is caused
by defective reaction to external impressions in conscious-
ness. In the process of perception those memory pictures
do not appear rapidly or in any number, which make it
possible for us to connect at once what is perceived with
former experiences, and to place it without difficulty in the
familiar circle of ideas. Through this the patients become
more or less incapable of working up their experiences
mentally or of understanding them. They often declare that
in spite of every effort they are not able to understand the
meaning of what they read or to follow an explanation,
" Like a mist it lies over everything," complained a patient,
and another said he was " no longer so capable of noticing
anything " as formerly. In the most severe grades of the
disorder, in states of stupor, the patients may regard the
external world with a complete lack" of understanding, even

PSYCHIC SYMPTOMS

when individual sense perceptions are fairly well appreciated.

The fact must also be taken into consideration that as a
rule facility of attention is distinctly disordered. The
patients are not able to turn their attention easily and
quickly to any impressions or ideas. They are not able
either to pay attention, or to turn away of themselves from
ideas which emerge in their own minds or which are suggested
to them from without. This lack of freedom of attention
certainly displays innumerable gradations.

Consciousness is in the severe forms of the malady in- -
variably somewhat clouded. At the height of excitement
impressions and ideas become dim and indistinct. In con-
sequence accuracy of orientation suffers. The patients do
not know properly where they are. .Everything is enchanted,
" not right " ;^_they are in the " freernason house," in the
"resurrection house, TmdeTgrDuhd^,nLn purgatory, in heaven,
^l^ite-away-from the world^' .They mistake ;people, think
that the nurses are spirits, the physicianjthe deviL\ ATefnale
patient takes the pafieht irrtKe next bed for the Virgin Mary,
a former sweetheart of her husband, for her husband himself.
They greet physicians and fellow-patients by the names of
relatives or acquaintances. These mistakes are sometimes
connected with remote resemblances ; in other cases they
appear to be more an amusing game in which the patient
takes pleasure, partially conscious of the arbitrariness of the
designations. That occurs especially at the decline of excite-
ment, when the wrong designations are still adhered to,
while from the other conduct and occasional utterances of
the patient it is evident that he is quite clear about his place
of residence and the people round him. In states of de-
pression also we encounter more or less 3eep clouding of
consciousness up to almost complete oblivion^ Here and
there a peculiarly dreamy stupor devefops, in which the
patient experiences the most extraordinary and confused
delirious adventures.

Memory is not permanently encroached upon by the
disease, but the patients frequently lose for a time the
mastery over their range of ideas. Jispecially ia-states of

^jiepression they are often incapable^of- recolleeting, and are
some-times ndt—abk to .eaU-'tg' mind the simplest thingsfT*

"They have to consider for a long time before they can work
an arithmetical exercise or narrate an experience. They are
occasionally unable to name the year of their birth or to give
the names of their children. They become entangled in

8 MANIC-DEPRESSIVE INSANITY

obvious contradictions, which, however, are often corrected

after a quite short interval.

- ?[etentioivJn manic patients is, according to Wolfskehl's
investigations, disordered in a similar way to perception. This
/ is represented in Fig. i, in which the values are given for the
I retention of letters in normal individuals, and in patients,
1 after periods of 5, 20, and 40 seconds. It is seen that the
{number of correct results in patients is invariably smaller,
and on the other hand the number of mistakes considerably
greater than in normal individuals, especially after the longer
intervals. Erroneous processes are obviously developed
which cause falsification of the memory pictures.- As in-
vestigation of the mistakes shows, divergence to linguistic
associations plays a certain part here. The fact is also
perhaps not unimportant, that the average values of the
manic patients in the shorter periods show much more clearly
than those of normal individuals a diminution of correct
values (from 1.19 to i.io), a behaviour which in individual
patients is still much more in evidence. Certain experiences
give ground for the belief that this is a sign of greater fluctua-
tion of attention.

Distinct Pseudo- memories are not infrequently met
with in the patients, especially in mania ; they correspond
to the results of the experiments. Occasionally they show
in a pronounced manner a tendency to delusional tabulation,
to descriptions of wonderful experiences out of the past,
which the patients more or less seriously believe. Memory
of the period of disease itself is usually somewhat indistinct,
especially after severe manic excitement or after states of
stupor. Experiences from childhood are often constantly
and in good faith represented essentially otherwise than
they actually occurred, a circumstance which prevents the
patients even on recovery from taking up the right attitude
towards their own conduct and towards their surroundings.

. Isolated Hallucinations are observed frequently and
in tHelmost diferent states, fatthough they~3o not very "oHeiT"
"appear"Tm!spicuousl3r^ri the foreground. It is generally a
case of illusionary occurrences, the appearance of which is
favoured by the incompleteness and slightness of perception,
but especially by the lively emotions peculiar to the disease.
"The substance of the illusions therefore-is invariably in close
connection w'ltlnlTe trains of thought and the moods of the
patients. J Their surroundings appear changed to^ them ;
faces are double, niaric ; 7 their ^wn faces look black in the

PSYCHIC SYMPTOMS 9

mirror ; they see a blaze of light, white fumes, " opium-
morphia-chloroform vapour," flickering, the shadow of a
man at the window, a figure in the corner. People are

< changed'; they look like " phantoms " ; their children appear
exchanged ; the ph3^sician is " only a sort of image " or the
devil, ; The chairs are moving^; the pictures make signs with
their eyes ; lirpiece~orbrownpa^eTlschanged^4nte^-^the^ skull

_ of a princess. 1

The patient hears a murmuring and a whispering, a roar-
ing, Jthe crackling of hell ; he hears someone coming up the
steps, going to the " larder," " the devil carrying on in the
walls," death gnashing his teeth in the wall, noises " as if a
corpse were being thrown out at the window," an uproar in
the stove as if a man wanted to get into it. There are noises

-in his headj_it sounds like tolling of bells and the murmur
of the ocean, like cries for help, shooting, the death rattle and
"groaning, screaming and howling, weeping, entreating and
lamenting, clamouring and cursing.' " In all the noises there
is something,"" said a patient in very significant tones.
Spirits buzz about each other ; others snarl something which
has some connection with the patient. Occasionally the
illusions are related to definite impressions. The birds call
out the name of the patient ; they whistle, " Come, Emily."
The clock says, " You dog, you're still here, you've brought
your father into the madhouse, you're the devil, a swine."
The rhythmic vascular murmur in the ear becomes a re-
proach, " bad, bad," or " whore, whore," which then is
ascribed to the devil.

Besides these illusions which clearly betray the influence
of emotions, real hallucinations also appear often enough.
At night disguised figures come into the room. ' The patient
sees an open grave^his dead wife, the apostle Paul with good
ang£ls.,^e Saviour on the cros's,' the Virgin Mary, Jesus with
roses, the £y-e.xif God, the deviE He sees corpses, skeletons^
_^^sad spirits," monsters, the heads of his children on the wall,

V fiery^TiiTgs "whiclT signiFy his sins. In the daytime also
caTicaTures appear before him, coloured figures, and faces like
the one in Fig. 2, which was drawn by a female patient.
They grin at him out of the book which he wishes to read,
from the bedclothes, from the wall ; they look in at the
window. Worrris_swaiTn in the food, and small heads which
iave beerfcut off.^;_A patientrsa:^ a nail with_a noose, which
was^ a- summons to hang himself. '

Through wall and window sound warning voices, cries.

MANIC-DEPRESSIVE INSANITY

the devil's laugh, the weeping of the dead mother, the
screaming of children, the song of angels. The content of
the -hallucinations of hearing is usually unpleasant and-
alarming. All possible sins are brought before the patient

as if he were a criminal ; he is enticed to suicide. . " Do

' —^ — — — — f. —

something to yourself," " Hang yourself," " If he would only
hang himself, otherwise we must keep him for ten years yet.j'
" You (1(il; of a parson, Prussian dog, thief and murderer."
are among the things called out, also " masturbator,"
" poisoner, wild swine," " swine," " you skunk, camel,"
" frightful creature," " Cindcnlla, cattle," " base female,"

Fig. 2. — CaricaliHi- ■•' ■•\\ \-\ h.
" O, how she stinks ! "" You iiuist die like a beast," " You
must go along," " Do away with him ! " the voices threaten,
" You're going to hell," " Get out of this, you've no right
here ; God docs not die," " Now someone's coming for you,"
"He's runniii- up tlwre, he'll never get away," "We'll
drive her out and make the maid the mistress," " She daren't
go away now ; she'll be cut," " We'll put something into
him and then he'll sleep and no mistake." Much more rarely
pleasant things are announced by the voices. A female
patient heard singing which made known to her that she was
the Virgin Mary ; another heard that her son had gained
millions. A male patient heard " sacred things of Ciod."

PSYCHIC SYMPTOMS ii

Auditory hallucinations frequently appear only in the
night-time, or at least much more then. They seem, as a
rule, not to possess complete sensory distinctness. They
are voices " as in a dream," " from the underworld," " voices
in the air, which come from God," more rarely gramophone
or telephone voices, wireless telegraphy. Their origin is
relatively seldom referred to the external world. The bed
speaks ; God speaks ; the dead sister is calling ; the voice
of Jesus is heard ; a white violet says, " It is the will of God " ;
the dead father declares, " I am behind you, I am speaking."
Much more frequently the hallucinations have their seat in
the patient's own body. There is speaking in his stomach,
in his left ear ; words are whispered inside him. The devil
speaks out of the heart of the patient ; he swears in him ;
the patient hears him " inwardly, not with his ears." " An
inward voice from the heart says filthy things about God,"
said a female patient. Another heard " voices coming from
within, which lament." " There is talking in my head along
with my thoughts," declared a third.

The voices generally stand in the most intimate relation
to the remaining content of consciousness. The patients
declare that they are questioned ; their thoughts are repeated
loud out after two or three minutes. Others carry on con-
versations with their voices. A female patient said that she
heard talking in her body, to which there were answers,
" more as if thought " ; another stated that people said what
she herself had already said. Now and then commanding
voices are heard, for the most part in the sense of self-
destruction, as mentioned above.

As the illusions do not usually reach the degree of im-
portunate sensory distinctness which they do in, for example,
alcoholic insanity or in dementia praecox, the patients are
generally unable to give the words of longer sentences, but
only the substance. Nevertheless a female patient wrote
that she had heard how her neighbour said, " Her blood is
being decomposed, and all nourishment goes to her flesh, and
then her face will be swollen Hke a pig's, and her eyes will
quite disappear," whereupon another replied, " But that
can't come of itself — she must have been a dreadfully bad
girl— and think of the number of young people, who were
always in and out of the house," It is, however, very
doubtful to me after former experiences whether such utter-
ances, which in this case reproduced the constant self-
tormenting of the patient, are really heard word for word,

12 MANIC-DEPRESSIVE INSANITY

Compared to illusions of sight and hearing, those of other
senses aie quite insignificant. There is a strong smell in the
house ; the exhalation from the patient's body has a frightful
stink ; his food tastes mawkish or putrid, like human flesh or
privy manure. The bed is moving ; electric currents pass
through it. On the other hand dysaesthesiae appear in great
number and variety, and they sometimes dominate the whole
state Extraordinarily frequent are headaches, attacks of
migraine, dull oppression, the feeling of a band round the
forehead, of a heavy helmet, of a lead plate. In the rest of
the body also pains of all sorts are felt. Schroder observed
them in 62% of his cases. The tongue is sensitive ; the back
aches as if it had gone to pieces, pains shoot from the
urethra to the larynx ; there is raging and burning in the
body. In one of my patients the disease began with such
violent lumbago, that when all other remedies failed, the
coccyx was amputated as an attempt to procure alleviation.
There are also sensations of crawling, pulHng, beating in the
head, dragging in the legs, crackUng in the bowels, pangs
and " shameful feelings " in the abdomen.

As an illustration I quote the following fragment from
the description which a female patient gave of herself. She
thought that she had brought a serious disease (syphilis) on
herself by onanism.

" Six months ago the patient was awakened by two violent blows on the
body ; at the same time violent beating in body, heart, backbone, and the
back of her head, trembling in hands and feet, in which the veins were
greatly swollen. Leaden pallor of her face ; flatulence. After a few weeks
the veins went down, and on her hands and especially on the joints, pricks
as of a thousand needle-pricks. The skin on her hands became shrivelled
and leathery, especially in her bath as if it could be pulled off. When it was
pricked or cut, scarcely any blood appeared, sometimes a whitish fluid.
Violent burning in her eyelids, lips, tongue and palate, thereafter spots and
holes in her skin, as if made with a red-hot point. Small, red spots as in
old people. Then a trickling in her whole body as if the vital fluid were
curdling, and in her joints like red-hot lead. Whites. Irregular period,
which was for long absent, and when it came back, the blood was thinner
than formerly as if the blood had no sticky substance in it. At first a great
flow of urine, then very slight and a motion only after an enema. Later a
strong smell of urine and forces, and her feet which were mostly cold and
shrivelled, as if dead, perspired at times copiously with the same smell.
The pulsation of the blood and the great beating decreased, but finally a
crackling in her head, as if something were drying up, was specially alarm-
ing ; in her ears ticking as of a watch, so that lying on the pillow became a
torment. The trembling of her hands and arms increased very much.
Great emaciation of the abdomen, a falling in of the thorax. When she
lay down, her body hot as lead. Decrease of eyesight. Flesh withered.
Her skin peels off in small flakes. Sometimes a slight smell of burning in
the skin. Her blood is so hot, as if it were boiling away. For some time
patient has mcreased in body-weight — but apparently everything goes to

PSYCHIC SYMPTOMS 13

flesh and nothing to blood, for the veins continue to disappear. At her
elbows her flesh is painful, as if it were coming away from the bone. The
pulse at her wrist is becoming harder. A feeling at her temples as if a hot
hand were laid on them. Increasing indifference. In her skin no activity.
When her hands perspire, small secretions like splinters of glass are seen,
and so on."

One sees here that it is largely a case of simple hyper-
aesthesia, but also of delusional interpretation of harmless
sensations. That becomes very clear when the patients say
that they feel their food going straight into their blood-
vessels, their mucous membranes and glands corroded, their
nerves loosened, fat, marrow, and albumen lacking in their
blood, the inward working of their bodies, white worms
drawing everything out of their bodies and creeping about
between their different skins.

This heightened sensibility for the processes in their own
bodies is in vivid contrast with the lowering of central ex-
citability in manic states. We observe here a very striking
lack of sensibihty towards heat and cold, hunger and thirst,
pain and injury. The patients expose themselves for hours
at a time to the most burning sunshine, take off their clothes
in a winter temperature, forget to eat and drink, regardlessly
tear off the bandages from their sores, and ill-treat diseased
parts of their body or their fractured limbs without giving
any sign of discomfort. Nor do fears for health and life,
fully justified by the circumstances, appear in them, or they
are without hesitation treated as of no consequence.

The Train of Ideas of our patients invariably ex-
hibits very important and well marked disorders. In states
of excitement they are not able to follow systematically a
definite train of thought, but they continually jump from
one series of ideas to a wholly different one and then let this
one drop again immediately. Any question directed to them
is at first perhaps answered quite correctly, but with that are
associated a great many side remarks which have only a very
loose connection, or soon none at all, with the original subject.
In consequence of these continuous interpolations and in-
cidental remarks the patients are quite incapable of narrating
any fairly complicated event, unless they are always brought
back anew to the subject by constant interruptions and
questions. The train of ideas is accordingly no longer
dominated, as in normal people, by a general idea, which
at the time admits only one definite direction of thought-
association and inhibits all secondary and chance ideas.
Therefore, at every moment the ideas favoured by generalj

14 MANIC-DEPRESSIVE INSANITY

habits of thought gain the upper hand, and not those re-
quired by the whole connection. It thus comes to digression
from one idea to others similar or frequently associated with
it, without regard to the goal of the original train of thought.
The coherence of thinking relaxes more and more ; there
arises that disorder which we have come to know as confusion
with flight of ideas.

The Flight of Ideas often becomes very distinctly
noticeable to the patient's own perceptions. They complain
that they cannot concentrate or gather their thoughts to-
gether. The thoughts come of themselves, obtrude them-
selves, impose upon the patients. " I can't grasp all the
thoughts which obtrude themselves," said a patient. " It
it is so stormy in my head," declared another, " everything
goes pell-mell." " My thoughts are all tattered," "I am
not master over my thoughts," " One thought chases the
other ; they .just vanish hke that," — these are further utter-
ances, which give us a ghmpse into these processes.

In depressed patients also flight of ideas occurs not alto-
gether infrequently, though certainly without being very
recognizable in the scanty speech of the taciturn patients ;
sometimes it appears distinctly in copious written utterances.
The patients complain that they " have so many thoughts
in their head," that they cannot pray, cannot work, because
other thoughts, " interpolations," come between, that they
have " no settled thoughts," that they have to think of
everything possible. Even an immediate change between
flight of ideas and inhibition of thought, which is to be dis-
cussed later, appears to occur often. " My thoughts stand
still," complained a female patient ; " then they come again
of themselves and run where they will."

As the flight of ideas only represents a partial phenomenon
of the heightened distractibility, we generally observe that
patients with flight of ideas, so far as they are at all accessible
to external impressions, can be caused by these to let their
train of thought take a new turn which is then reflected in
their talk. An object, on which their eyes fall, anything
written, a chance noise, a word, which sounds in their ears,
is immediately woven into their talk and may call forth a
series of similar ideas which often are only associated by
habits of speech or are related by sound. The capacity to
observe and to perceive is by no means raised thereby.
Rather do the patients perceive as a rule only very super-
ficially and inaccurately, and they do not take themselves

PSYCHIC SYMPTOMS 15

up speciall}^ with what goes on around them. But when
they notice anything, their train of thought is immediately
influenced by it and generahy also their flow of talk ; they
express their perception in words and let themselves be
aimlessly driven along by the impulse given by it.

Association Experiments have yielded very im-
portant conclusions about the train of thought of patients
with flight of ideas. These experiments have been carried
out principally by Aschaff^nburg and Isserlin.^ The former
was able to demonstrate that the association reaction times
in manic patients are by no means accelerated, but often
even definitely retarded, contrary to the idea which originally
was the fundamental signification of the expression " flight
of ideas." To this the experience corresponds, that well-
marked flight of ideas is observed not altogether infrequently
even in quite slow talk. Franz also arrived at the same
result. Isserlin has specially investigated the duration of
ideas in manic patients. He found that their associations
show heightened distractibility in the tendency to "diffusive-
ness," to spinning out the circle of ideas stimulated and
jumping off to others, a phenomenon which in high degree is
peculiar to mania. Kilian and Gutmann emphasize further '
the frequent repetition of the stimulus word. Isserlin was
able to ascertain also with help of continuous associations
that a change of direction of the train of thought took place
in normal individuals about every 5 or 6 seconds, in a female
manic patient on the other hand even after 1.6 or 1.7
seconds. The duration of an isolated idea in consciousness
could be reckoned on the basis of phonographic records for
the patient mentioned at about i second, while for two
normal people it fluctuated between 1.2 and 1.4 seconds.
The essential characteristic of the manic train of thought is
therefore above everything the fleetingness of isolated ideas ;
they do not persist in consciousness but vanish very quickly,
when thay have scared}^ reached development. " My
thoughts are so rapid that I carmot hold them fast at all,"
said a patient.

Inhibition of Thought appears to form the exact
opposite to flight of ideas. It is observed, more or less
strongly marked, almost everywhere in depression, further
in certain manic-stuperous mixed states and in forms of
manic excitement related to these. The patients exhibit an
incapacity, often very painfully felt by themselves, to order

1 Isserlin, Monatsschr. f. Psych, u. Neurol., xxii., 302.

i6 MANIC-DEPRESSIVE INSANITY

their own ideas aright. As it appears, isolated ideas develop
slowly and only in response to very powerful stimuli. In
consequence of this an impression does not of itself awaken
rapidly and easily a great many associations, among which
only a choice has to be made. Association, therefore, occurs
mostly according to the content of the ideas, not according
to external, linguistic or sound relations. Generally nothing
at all occurs to the patients at first, and the train of thought
must be laboriously spun out by a special effort of volition.
Thus arises a great dulness and retardation of thought,-
thoughtlessness in answering simple questions, lack of under-
standing and poverty of ideas. " I cannot think any longer,
I cannot imagine anything any more, cannot reflect any more,
my head is empty," the patients complain, "my mental
capacities are going back, I am as if mentally dead," " I am
as in a dream, apathetic, and I don't know anything."
Sometimes another complaint is associated with these, that
their ideas are colourless and faded, the patients feel them-
selves incapable of recalling any impression, or occurrence,
landscape, painting, or the appearance of their dear ones.
They know quite well how the things look, and can even
describe them, but the sensuously coloured memory picture is
lacking in them.

Such patients produce only a conspicuously meagre
number of ideas, even when apparently they are not at all
hindered from expressing their thoughts. They are then
generally considered very weak-minded, while the further
course shows distinctly that here it was only a case of thought
having become difficult, not of an annihilation of the store of
ideas.

On the other hand the ideas once developed are not ousted
by the emergence of fresh series of thoughts, but they fade
slowly and often persist with great tenacity, especially when
they are firmly rooted in temperament. The consequence
then of this is an extraordinary uniformity of ideational con-
tent. The patients ever again bring forward the same
thoughts, do not let themselves be turned aside to other
domains, return after every intervening question innnediately
to the old complaints. " I have to rack my brains for hours
about everyday reproaches and things," declared a patient.
Now and then the ideas, which ever anew force themselves
on the patients against their will, acquire completely the
stamp of obsessions. The patients are tormented against
their better knowledge by the con^^fnnt (<■:>'- tliu fjiey have

PSYCHIC SYMPTOMS 17

killed someone, pushed some one into the water, trodden
under foot the host, swallowed a needle, driven a splinter into
their foot, soiled the water-closet.

Association Experiment gives a wholly different
picture in depressive patients from what it does in manic
patients. A good idea of this relation is given by the follow-
ing table taken from the work of Isserlin. It compares two
association experiments on a patient, who at the time of the
first one on April 25th was in a manic state, at the time of the
second on September 8th was suffering from depression : —

Internal
Association.

External
As.sociation.

Digression.

Clang
Reaction.

Repetition of
Stimulus Word.

Median

Middle
Zone.

Per cent.

Per cent

Per cent.

Sec.

April 25

. 18

81.5

22.3

I.O

0.2

Sept 8

. 81

—

1.9

—

The duration of the association time has risen fivefold in
depression, and the " middle zone," which cuts out the middle
half of the values gained, thus giving a good idea of the
scatter of the numbers, also shows a considerable increase ;
the association times have not only become longer, but also
much more unequal. The relation between internal and ex-
ternal associations has been completely reversed ; whereas
in mania the associations according to external relations,
especially after linguistic practice, are greatly in excess, they
decrease greatly in the depressed patients in favour of
associations dependent on content. As a further expression
of this displacement the almost complete disappearance of
pure clang associations may be taken, which play such a large
part in mania. In the same way digression which is so
characteristic of the distractibility of manic patients is com-
pletely absent in depression, and lastly also the repetition of
the stimulus word, which is frequent in manic patients and is
probably caused mostly by inattention.

Mental Efficiency is invariably lowered in mania, with
the possible exception that in the very slightest cases of manic
excitement, the volitional excitement which accompanies the
disease may under certain circumstances set free powers
which otherwise are constrained by all kinds of inhibition.
Artistic activity namely may by the untroubled surrender to
momentary fancies or moods, and especially poetical activity
by the facilitation of linguistic expression, experience a
certain furtherance. This favourable effect is usually parti-
cularly conspicuous in comparison with the inhibitions of the
depressed periods. In all the more pronounced forms of

l8 MANIC-DEPRESSIVE INSANITY

manic excitement, however, the unfavourable influence of
heightened distractibility and of unsteadiness of volition is
predominant. It is moreover easy to convince oneself that
the patients in their desultory trains of thought are by no
means rich in ideas but only rich in words ; often enough it
comes to very monotonous repetitions. The occasional jokes
of such patients are almost always simple plays on words,
just as they are called forth by the tendency to clang associa-
tions. We find them as we find the tendency to speak in
foreign languages, and a series of similar features in acute
alcoholism, in which the paralysis of intellectual activity can
be demonstrated with complete certainty. In spite of this
and in contrast with the results of measurement we frequently
meet with the self-deception of heightened mental efficiency.
There is just as little evidence for it as there is for the idea of
special mental freshness and health which arises from the
manic feeling of well-being.

In contrast to that, the feeUng of mental inhibition in
states of depression is often greater than the actual lowering
of efficiency, probably because the inhibition of thought can
be overcome up to a certain degree by volitional effort, but
just by that it becomes especially distinct to consciousness.
The patients complain that they feel themselves " as if under
a ban," as if fettered, that their thoughts are paralysed, that
they now need hours for the simplest mental activity, as for
example writing a letter, which formerly they could accom-
plish in a few minutes.

In order to ascertain more accurately the value of the
mental efficiency, I have repeatedly had arithmetical experi-
ments carried out with manic-depressive patients according
to the procedure usual in fatigue measurements. Rehm in-
vestigated, one after the other, twenty-four normal individuals
and thirty-four patients in the most varied states. He found
that the work of the patients remained on an average about
one-third behind that of the normal individuals. In manic
patients the results were in general better than in depressed
patients. The patients whose efficiency was most en-
croached on were those who exhibited cUnically distinct in-
hibitions, and also depressed patients with excitement. The
progress owing to daily practice was on the average less than
in the normal individuals, once even negative, but a few times
it exceeded the highest values of normal individuals. These
experiences point to the fact that here probably, sometimes
in the course, sometimes in the beginning of the experiment.

PSYCHIC SYMPTOMS 19

inhibitions have lowered efficiency to an unusual degree. In
the same sense the observation has to be interpreted that the
recovery effect of a pause interpolated in the work remained
in almost half of the patients behind the lowest values of the
normal individuals, and in more than one-third of the cases
was even negative, a result that might never occur among
normal individuals. Here, even in the pause, inhibitions must
have been developed, which in certain circumstances pre-
vailed over the recovery effects.

The experiments carried out by Hutt on eight manic and
seventeen depressive patients also gave in general as result a
lowering of arithmetical efficiency, which, however, in the
former was only very trifling, so far as the difference in
education at all allows a comparison to be made with the
normal individuals investigated. Improvement due to daily
practice remained behind that of normal individuals and in
one case was negative. Likewise in several cases negative
values were recorded for the recovery effect of the pause ; the
unfavourable effect on the output of the interruption due to
the pause was throughout greater than in the normal in-
dividuals. Lastly, the experience is very noteworthy that
in some cases, wholly contrary to the behaviour of normal
individuals, an increase of output in continuous work without
a pause was connected with the lowering of output after the
pause, a circumstance which can only be related to a removal
of influences inhibiting work by continuous work, this re-
moval of influences being stronger than the effects of fatigue.
It appears, accordingly, what moreover completely corre-
sponds to clinical experience, that in our patients the
hindrance to work may be weakened with comparative
rapidity by effort and stimulus, while on the other hand after
cessation of activity it soon returns and in certain circum-
stances to a greater extent.

-Delusions are in manic - depressive insanity very fre-
quent, ^esj^eci^Lllyin states of depressiiSn. f' Their'^ihiples'E

"Torms are connected~"wi1±~^e "fe^lm^of ihental inefficiency, ^
and exhibit a hypochondriacal content. Th,e4iati£iitJia§_Jtlie__

^ ideajthat he igJurnrpLly-ill/hopBlasslyJoslv \( He suffers from
cancer, syphilis, softening of the brain, is becoming demented,
is having an attack of apoplexy, is ill in his body and soul, a
desperate case ; his future will be a slow and tedious death.
His body has taken on a quite different form ; his nerves are
dried up, his organs withered ; his brain is obstructed with
mucus, everything internal is dead, his voice is Hke tin ; the

20 MANIC-DEPRESSIVE INSANITY

blood does not circulate in his brain any longer ; his penis
does not recover itself again. Occasionally these ideas
acquire a very extraordinary content, so that one is re-
minded of the delusions of paralytics. His brain is only pulp,
his head the size of a finger joint ; his lungs and stomach are
gone, his genitals are shrivelled ; his palate is withered, his
gullet is done for ; in his body everything is sewn up and
entangled ; there is a bone in his throat.

Ideas of Sin are almost more frequent. He reflects
on his past life, finds that he has not fulfilled his duties, has
committed many sins, has been disloyal to his Saviour. He
was not grateful enough to his parents, has not taken good
care of his children, has treated them badly, has not sent for
the doctor immediately when there was illness, has not
looked after them well enough. He has not discharged bills
punctually, has committed lese-majesty, has neglected re-
ligion, has been dishonest about taxes, has masturbated, has
committed adultery, has confessed and communicated un-
worthily ; he has been " frivolous in every relation," " a
thoroughgoing rascal." Even these ideas may become more
and more remote not only from reality, but also from possi-
biUty. The patient has committed perjury, offended a
highly placed personage without knowing it, carried on
incest, set his house on fire, killed his brothers and sisters.
He has poisoned a prince, is a fivefold murderer, is to blame for
every misfortune, is a damned soul, the refuse of humanity.

Ideas of Persecution are comewhat rarer ; they are
^frequent Iv connected with the delusion ol sin. The patient
sees that he is siirrouaded by spies,\ is being followed by
^^etectives, has fallen into the haiids of the secret court of
justice, of an avenging l^'emesis, is going into the convict
prison, is to be slaughtered, executed, burned, nailed to the
cross ; all his teeth are being drawn out, his eyes dug out ;
he is inoculated with syphilis ; he must putrefy, die in a filthy
manner. He is despised by his neighbours, mocked, is no
longer greeted ; they spit in front of him. There are
allusions in the newspapers ; the sermon is aimed at him ;
his sins are publicly made known on large placards.
Burglars, anarchists, force their way into his house ; people
are hidden in the cupboards. The patient notices that there
is poison in the coffee, in the water for washing, feels himself
hypnotized, magnetized ; people try to lead him astray by
putting money in his way ; there is a conspiracy against him.
His relatives also become involved. His family must dieof

PSYCHIC SYMPTOMS 21

hunger ; his mother is being dismembered, his brother be-
headed ; the husband of a female patient is being arrested.

The domain of rehgion usually pla3/s a considerable part
here. The patient thinks that he is spied on in the con-
fessional ; he is shut out of the church, is excommunicated,
has lost eternal salvation, must do penance for everyone,
take the sins of the whole world upon himself. Satan has
power over him, is hiding inside him, will command him to
swear, will take him away because he is no longer worth any-
thing. God Almighty does not like him any longer ; his
prayer has no longer power ; hell-fire is already burning
under the bed.

Ideas of Greatness. — While all these delusions usually
go along with profound emotional agitation and are brought
forward and defended by the patient with the greatest con-
viction, the ideas of greatness, which not infrequently accom-
pany the manic state, often bear more the stamp of half
jocular swaggering and boastful exaggeration, which also in
contrast to the depressive ideas for the most part uniformly
adhered to, change frequently, emerge as creations of the
moment and again disappear. In more sensible patients,
however, delusions may be observed which are psychically
finer spun and which persist more obstinately. To the first
group belong the assertions of the patients that they are
Messiah, the pearl of the world, the Christchild, the bride of
Christ, Queen of Heaven, Emperor of Russia, Almighty God,
that they have ten thousand children. Others allege that
the Czar is their fiancee ; they have been overshadowed by
the Holy Ghost, have annihilated the devil, can cure all
patients by hypnosis. The ideas are less nonsensical, that
they are a great artist or author, a baron, " physician by
birth," honorary doctor of all the sciences, a knight of high
orders, illegitimate son of a prince, that they have a higher
mission, speak seven languages, can hold up two hundred-
weight. A patient described himself as " a man of action,
immediately after Nietzsche . ' ' Large inheritances also usually
play a part. A patient who fancied that he was of aristo-
cratic origin, alleged that his share of the inheritance would
shortly be paid ; another represented himself as the son-in-
law of Rockefeller, and boasted of the dowry of a hundred
million which he had in prospect.

Insight." — A clear understanding of the morbidity of the
state is, as a rule, present only in the slightest states of de-
pression ; nevertheless here also it readily takes on a hypo-

22 MANIC-DEPRESSIVE INSANITY

chondriacal colouring with the idea of the hopelessness of the
malady. Very commonly it is asserted that the disease is a
greater torture than any other, that the patient would far,
far rather endure any bodily pain tlian disorder of the mind.
When the delusions are more pronounced, consciousness of the
illness is generally lost, even when former and similar attacks
are regarded correctly. At most once in a while the patients
reply to the representations of the physician, that they would
be glad if he were right ; unfortunately everything is only too
true of their torments. A female patient begged to be
allowed to make her will, as the fear was forced upon her that
on the next day she would be completely confused. In
manic states the patients mostly reject with emphasis the
suggestion of mental disease. " Whoever thinks that I am
mad, is himself mad," said a patient. At most they allow
that they have been rather excited, " a Uttle bit jolly."
Afterwards they occasionally even make fun of the ideas to
which they had given utterance ; it was " a little bit of
deUrium," " of course megalomania." A female patient said
on her morbid behaviour being pointed out to her, " Doctor,
you too sometimes do nonsensical things."

Mood is mostly exalted in mania, and in lively excite-
ment it lias the peculiar colouring of unrestrained merriment.
The patients are pleased, " over merry " or*" quietly happy,"
visionary, " more than satisfied," " cheerful in this beautiful
world " ; they feel well, ready for all possible sport and
banter, " penetrated with great merriment," they laugh, sing
and jest. They are " enraptured with everything," " the
happiest woman " ; happiness has come upon them ; " now
the days of roses are coming." The group of patients in
manic excitement (Fig. 3) reproduces the expression of this
mood in varied colouring from quiet cheerfulness and proud
self-consciousness to unrestrained cheerfulness.

Sexual excitability is increased and leads to hasty engage-
ments, marriages by the newspaper, improper love-adven-
tures, conspicuous behaviour, fondness for dress, on the other
hand to jealousy and matrimonial discord. Several of my
patients displayed in excitement homosexual tendencies.
When merriment is associated with poverty of thought, it
easily acquires the stamp of foolishness and silUness which
then may lead to the assumption of a state of psychic weak-
ness. Further, by the admixture of an unpleasant colouring
the disposition of the manic may assume the form of angry
irritation. The patients become arrogant and high flown ;

PSYCHIC SYMPTOMS

24 MANIC-DEPRESSIVE INSANITY

when they are contradicted, or on other trifling occasions,
they fall into measureless fury, which is discharged in out-
bursts of rank abuse and violence.

But the circumstance is very important for the manic
mood, that it is invariably subjected to frequent and abrupt
fluctuations. In the midst of unrestrained merriment not
only are sudden attacks of rage interpolated, but also un-
controllable weeping and sobbing, which certainly give place
again just as quickly to unrestrained cheerfulness. " I don't
know whether to laugh or cry," said a female patient. In
this alternation of mood, which in a similar manner, although

^faf less pronounced, is frequently found also in states of de-
pression, the close internal relationship of the clinical states,

^apparently so fundamentally different, is seen.

' The fundamental mood in the states of depression is most
frequently a sombre and gloomy hopelessness. The patient
has " whole hundredweights on him," is lacerated with grief,
has lost all spirit, feels himself deserted, without any real aim
in life. His heart is hke stone ; he has no pleasure in any-
thing. As it appears, it is here a case not only of gloomy and
sullen humour, but also of a certain inhibition of the emotions
which is the antithesis of the free flow of the feelings in mania.
It is exactly this decrease of emotional interest, the loss of

1, inner sympathy with the surroundings and with the events of
life, which the patients usually feel most bitterly. Within them
all is empty and vain ; everything is indifferent to them, is
no concern of theirs, seems " so stupid " to them ; music
" sounds strange." They have a feeling as if they were
wholly out of the world ; they cannot weep any more ; they
experience neither hunger nor satisfaction, neither weariness
nor refreshment after sleep, no longer any bodily desire ; God
has taken away from them all feeling. A female patient com-
plained that she was annoyed, if she saw other people doing
anything with interest. " I am hke a stock," complained
another patient, " and feel neither joy nor sorrow." Indeed
it is easy to convince oneself that the patients are surprisingly
little affected by bad news. Natural grief usually breaks out
first in convalescence. Even when their relatives visit them,
they often show no interest, scarcely look up, make no en-
quiries. On this account they sometimes appear dull and
without feeling, although it is not a case of annihilation of
emotions, but only of inhibition.

More rarely than the sombre and sad melancholy just de-
scribed anxiety is the principal feature of mood. Sometimes

PSYCHIC SYMPTOMS 25

it is more " inward anxiety and trembling," a painful tension,
which can rise to mute and helpless despair ; sometimes it is
an uneasy restlessness, which finds an outlet in the most
varied gestures, in states of violent excitement, and in regard-
less attempts at suicide. In other cases again, we meet with
a peevish, insufferable, dissatisfied and grumbling mood.
The patients are discontented with everything ; they loathe
the whole world ; everything torments, annoys, irritates
them, fills them with bitterness, the sunshine, people enjoy-*
ing themselves, music, everything done or left undone in their
surroundings. These moods are most frequently found in
the periods of transition between states of depression and
mania ; they are, therefore, probably most correctly regarded
as mixed states of depression and manic excitability.

The torment of the states of depression, which is nearly
unbearable, according to the perpetually recurring state-
ments by the patients, engenders almost in all, at least from
time to time, weariness of hfe, only too frequently also a great
desire to put an end to life at any price. " There's nothing
to be done with me but powder or in water," said a female
patient, and another expressed herself thus, " Millstone round
my neck, and then to the bottom of the sea." The patients,
therefore, often try to starve themselves, to hang themselves,
to cut their arteries ; they beg that they may be burned,
buried alive, driven out into the woods and there allowed to
die. In carrying out injuries on themselves they are often
quite indifferent to bodily pain. One of my patients struck
his neck so often on the edge of a chisel fixed on the ground
that all the soft parts were cut through to the vertebrae.

Out of 700 manic-depressive women, whom I observed in
Munich, 14.7% made serious attempts at suicide ; of those,
who on admission were over 35 years of age, 16.2%. Among
295 men 20.4% attempts at suicide were reported. The
otherwise much greater difference in the tendency to suicide
of the two sexes is thus largely obliterated by the disease.

Even in states of depression the mood, as already in-
dicated, is not necessarily always the same, although the
fundamental feature here often persists with hopeless
obstinacy. Without taking into account the fact, that not
at all infrequently for a short time there may be a complete
change to the manic state, we are often surprised by a forlorn
smile, a sudden gaiety, which appears quite abruptly in the
midst of self-accusation and ideas of persecution. " It's a
misery," said a patient with a contented look. Occasionally

26 MANIC-DEPRESS1\'E INSANITY

the patients develop a certain grim humour ; they scoff at
their own complaints and treat them ironically, calling them-
selves with a querulous laugh silly cattle One patient called
himselj a " magnificent masturbator." Specially chtiracter-
istic, and in certain circumstances of definite diagnostic
significance is the experience that, when the moodiness is not
too severe, it is frequently possible to persuade the patients
to look pleasant. The suddenness with which the relaxed
and troubled features then assume an expression of merri-
ment and high spirits, is extraordinarily startUng.

Pressure of Activity.^ — By far the most striking dis-
orders in manic-depressive insanity are found in the realm of
voHtion and action. In manic states the morbid picture is
dominated by pressure of activity ; here we have to do
with general volitional excitement. Experiment certainly
teaches that the duration of simple and discriminative re-
actions is invariably lengthened, sometimes even very con-
siderably. Many circumstances, however, point to the fact
that the lengthening essentially concerns the connection of
actions with external requests, which moreover are often im-
perfectly understood. On the other hand every chance
impulse seems to lead forthwith to action, while the normal
individual usually suppresses innumerable volitional impulses
immediately as they arise. The disorder might to a certain
degree conform to that which we can produce artificially by
alcohol ; from this arises the great similarity of many manic
patients to light or heavy drinkers. It is true that in drunken-
ness the encroachment on perception and thouglit is com-
paratively much greater than in our patients ; and besides in
the former the appearance of paralysis and uncertainty in
movement soon makes itself conspicuous.

Manic pressure of activity naturally leads to more or less
pronounced restlessness. In the slightest grades it is only a
certain restless behaviour, always busy about something,
which strikes us, an agitated desire for hurried enterprise.
The patients make all sorts of plans, wish to train as singers,
to write a comedy ; they send suggestions for reform to the
police magistrate or to the railway managers ; a clergyman
wrote a letter to the Pope concerning the marriage of priests.
They busy themselves with the affairs of other people, but
not with their own; they start senseless businesses, buy
houses, clothes, hats, give large orders, make debts ; they
wish to set up an observatory, to go to America. One patient
made the journey to Corsica and there bought property

PSYCHIC SYMPTOMS 27

for 85,000 marks, which involved him in endless law-
suits. They make plans of marriage, enter into doubtful
acquaintanceships, kiss strange ladies on the streets, fre-
quent public houses, commit all possible acts of debauchery.
A young girl went about with men in taverns and paid for
their beer. An elderly married man went walking on the
street with a negress from a music-hall. While they appear
in company as jovial fellows, give large tips, stand treat, they
quarrel with their superiors, neglect their duty, give up their
situations for trifling causes, leave public-houses without pay-
ing. A female patient travelled on the tramcar without a
ticket, and then asserted falsely that she had a season ticket.

Acute Mania. — In more severe excitement a state of
genuine mania is developed by degrees. Impulses crowd one
upon the other and the coherence of activity is gradually lost.
The patient is unable to carry out any plan at all involved,
because new impulses continually intervene, which turn him
aside from his original aim. Thus his pressure of activity
may finally resolve itself into a variegated sequence of
volitional actions ever new and quickly changing, in which
no common aim can be recognised any longer, but they come
and go as they are born of the moment. The patient sings,
chatters, dances, romps about, does gymnastics, beats time,
claps his hands, scolds, threatens, and makes a disturbance,
throws everything down on the floor, undresses, decorates
himself in a wonderful way, screams and screeches, laughs or
cries ungovernably, makes faces, assumes theatrical attitudes,
recites with wild passionate gestures. But, however abrupt
and disconnected this curious behaviour is, it is still always
made up of fractional parts of actions, which stand in some
sort of relation to purposeful ideas or to emotions ; it is a
case of movements of expression, unrestrained jokes, attacks
on people, amusement, courtship, and the like.

Only in very severe excitement may these relations be
effaced, sometimes even beyond the possibility of recognition.
The patients roll their eyes, turn their heads, roll about on
the floor, hop, bellow, turn somersaults, beat rhythmically
on the mattress, throw their legs about, beat as on a drum,
behave convulsively, gnash their teeth, spit and bite about
them. The movements may then in certain circumstances
be very monotonous and senseless, and may occasionally give
quite the impression of compulsion. A female patient
declared to me that she must always carry out peculiar move-
ments with her arms and head and say certain sentences.

MANIC-DEPRESSIVE INSANITY

" Laissez moi-laissez-moi travailler " ; another stated that
she must always beat the wall with her fist ; a third that she
had got out of bed " on command".

The pictures reproduced, Figs 4 and 5, afford so far an
idea of manic behaviour. The first shows a patient who has
plaited her hair for a joke in innumerable small plaits. The
second represents a patient who has made a picturesque

Fig. 4. — Manic patient with numerous plaits.

costume for herself from old garments, scarfs, and blankets,
and is displaying a number of works of art made of paper on
the lid of a cardboard box. I further reproduce some
pictures. Fig. 6, from a series taken by Weiler, which show a
patient witli a lively play of gesture in various impressive
attitudes rapidly alternating one with the other.

An Increase of Excitability also is invariably pre-
sent in our patients as well as excitement. Perhaps this is

PSYCHIC SYMPTOMS

even to be regarded as the essential fundamental manifesta-
tion. The patients are often fairly quiet as long as they are,
as far as possible, protected from every external stimulus, but
if they are spoken to, or some one comes to see them, or their

Fig. 5. — Decorated manic patient.

fellow patients begin to scream, excitement, rapidly growing
worse, appears with uncommon facility. The more they are
allowed to talk and to do as they please, the greater does
pressure of activity usually become, an experience very im-
portant for treatment.

MANIC-DEPRESSIVE INSANITY

The Feeling of Fatigue is completely absent in the
patient in spite of the most intense motor excitement which
occasionally persists in the highest degree for weeks, indeed

Fig. 6. — Changing attitudes of a manic patient.

for many months, with slight interruptions. He is not weary
and relaxed ; the ill usage of the muscle tissue produces no
sensation of discomfort, partly, perhaps, because of the blunt-
ing of sensibility previously discussed, but specially perhaps

PSYCHIC SYMPTOMS 31

because of the ease with which his activity discharges itself.
In him the shghtest impulse is sufficient to call forth abundant
movement, while for the attainment of the same result the
normal individual would require an incomparably greater ex-
penditure of central energy. On this account also every
attempt to imitate this state must necessarily in a very short
time fail, because of the impossibihty of overcoming the
paralyzing feehng of fatigue by a mere effort of will. This
circumstance, as also the regardlessness with which the
patients use their limbs, has led to the widely-spread, but
incorrect, view that they possess very great bodily strength.
But on the contrary the working capacity of their muscles is
invariably proved in ergographic experiments to be con-
siderably decreased. On the other hand the movements are
more quickly carried out than by normal individuals, especi-
ally when there is a continuous series of the same movements
and the patients fall into rapidly rising excitement.

Towards their surroundings the patients behave in very
varying fashion. As a rule they are easily influenced,
approachable, often importunate, erotic. At times they
become irritated, threatening and violent, but are then for
the most part quickly calmed by kindly or humorous per-
suasion. Man}^ patients are repellent, pert, abrupt, un-
approachable ; now and then waxy flexibility and echolalia
or echopraxis are observed.

Pressure of Speech, which is often very marked in the
patients, is a partial manifestation of the general pressure of
activity. The conversion also of verbal ideas into the move-
ments of speech is morbidly facilitated. Isserlin was able to
prove that the number of syllables spoken in a minute by a
manic patient amounted to 180 to 200, while the normal
control produced not more than 122 to 150. As we have
already remarked just this circumstance might play a certain
part in the peculiar form of the manic flight of ideas. The
easily stimulated ideas of the movements of speech gain too
great an influence over the flow of the train of thought, while
the relations of the contents of the ideas pass more into the
background. Thus it comes about that in the higher grades
of the flight of ideas, just as happens under the influence of
alcohol, forms of speech, which have been learned as such,
combinations of words, corresponding sounds and rhymes,
usurp more and more the place of the substantive connection
of ideas. As is already recognisable from the examples given
above, the pure clang-associations, in which every trace of an

MANIC-DEPRESSIVE INSANITY

inner relation of ideas has vanished, assonances and rliymes,
even though quite senseless, gain more and more the upper
hand. To what a height the disorder may rise, is shown in
Fig. 7, in which, according to Aschaffenburg's investigations,
the percentage of clang-associations in five normal individuals
and five manic patients is reproduced. The numbers for the
normal individuals fluctuate here between 2 and 4% ; but
they may with peculiar personal disposition once in a way
even be considerably higher. On the other hand they never
reach the high values of the manic patients which here. rise to
32 to 100%. A female patient wrote on a piece of paper,
Nelke — welke — Helge — Hilde — Tilde — Milde — Hand — Wand
— Sand.

Normal

Manic

Fig.

-Freciuency of clang-associations in normal individuals and
manic patients.

In the talk of the patient the flight of ideas and the
pressure of speech are both at the same time conspicuous.
He cannot be silent for long ; he talks and screams in a loud
voice, makes a noise, bellows, howls, whistles, is over-hasty
in speech, strings together disconnected sentences, words,
syllables, mixes up different languages, preaches with solemn
intonation and passionate gestures, abruptly falling from
high-sounding bombast to humorous homeliness, threats,
whining, and obscenity, or suddenly coming to an end in un-
restrained laughter. Occasionally it comes to Usping or
affected speech with pecuUar flourishes, also, it may be, to
talking in self-invented languages which consist partly of
senseless syllables, partly of strangely cHpped and mutilated
words. Among these are interpolated quotations, silly puns,

PSYCHIC SYMPTOMS 33

poetical expressions, vigorous abuse. Many patients speak
like children, in telegram style, in infinitives.

An example of manic conversation is given in the following
notes : —

" Notieren Sie genau, es scheint mir alles so grau ; die Uhr (a watch was
held in front of the patient) bedeutet den Kreislauf der Zeit ; Herr N. hat
einen Chronometer bereit. Mein Magen tut mir weh, immer hipp, hipp,
hurrah ! Der Geibel ist der Dichter, der Genius der Zeit gewesen, ete, der
Sommer muss kommen, die Baume schlagen aus, und du bist nicht zu Haus.
Roslein, so hold am Haag, mich doch niemand holen mag. Les extremes
se touchent ; Zeiten fiiehen so manches Jahr, mich doch niemand holen
mag. (to the waitress) Du Liider, du unverschamtes Saumensch, kannst du
dariiber lachen, dass die guter Hoffnung ist, von Rose gesprochen, drum
bist du Esel so grau. Grau, teurer Freund, ist alle Theorie. Stern, Blume
so gern. Der Grossherzog soil leben hoch. Leberecht Hiihnchen," and
so on.

The want of connection here is not at all caused by over-
flowing abundance of thought, but by deficient cultivation of
guiding end-ideas. The normal individual also may produce
very similar series, when he lets go the reins of his thinking
and says aloud whatever comes into his mind. Nevertheless,
in normal individuals, as the investigations of Stransky have
shown, the manifold variety of ideas appears to be con-
siderably less, in consequence of the involuntary per-
sistence of end-ideas and the sHghter distractibiHty which is
caused by that. In place of this variety there appear
enumerations as well as variations and repetitions of the
same thoughts. The patients also often produce enumera-
tions. A female patient called out, " Straubing, Osterhofen,
Vilshofen, Passau," and later, " Life, light, death, hell,
eternity."

As a rule the conversation of the patients is considerably
influenced by external impressions. They weave in words
which they have heard, connect up chance impressions, and
make them serve as starting-points for utterances spun out
by the flight of ideas. But occasionally in jocular manner
they directly evade all external stimulus, only laugh at every
question, repeating it in a teasing way, and purposely give
false or wittily elusive replies. A female patient always
replied with unrestrained laughter to everything that was
said to her, the one word " Nixen " (nichts). Another, on
being asked her age, replied, " Amn't born at all " ; when,
asked what is seven times seven, " One doesn't count any
more, one weighs, one measures." Lastly, it also happens
that the patients not only string together of themselves single,
words and incomplete sentences without connection, but-

34 MANIC-DEPRESSIVE INSANITY

also they pay no attention to the meaning of the questions
directed to them ; thej^ rather give utterance to completely
unrelated, nonsensical remarks. Many patients remain mute,
yet communicate with their surroundings by means of a very
expressive and comical language of signs.

In the writings of the patients there is a tendency to use
foreign words and to mix up different languages. The in-
fluence of clang-association on the sequence of ideas is here on"
obvious grounds much slighter than in speaking, especially in
the case of patients, whose internal speech does not by pre-
ference wholly take the form of speech motives or clang-
pictures. Instead of that it often comes to the enumerations
of similar ideas described in detail by Aschaffenburg, while
association according to external similarity, or according to
contiguity, takes the place of a progressive train of thought.
The increase of distractibihty and excitability are usually
seen in the circumstance that the first words or lines are for
the most part quite connected, whereas the remainder con-
sists of a confused sequence of enumerations, reminiscences,
scraps of verse, assonances and rhymes.

The following fragment of a letter of condolence contains
such derailments : —

" Ach ! gnadigste Frau 1 Komm' ich auch spat zu Ihnen, meine innigste,
wirklich aus meinem Hcrzen fliessende Teilnahme zu dcm Heimgange a la
Fidelio Thres teuren Florestan auszudriicken- — niemals kommt man dann
zu spat, wenn man sich irkgt : Ach, wie ist's denn moglich wohl, dass mir
so viele Schmerzen Dein Tod, Du treuer, lieber Seladon und Romeo Mir,
Deiner einzigen ach ! der teuren Gattin naht die . . . Ja die TrSnen ! ecc.
Pamela Questenberg Neumann Gordon a la Vitzthum Magdalena o Terzky
Struve Carola auch Du Graf von Lula o Leonore o Sollschwitz o Gitschin
Generalmajor von Schmieden aussi bientot Hauptmann qu'est que la
pardonnez ..."

Here we first meet the series Fidelio — Florestan —
Seladon — Romeo, which interrupts the original train of
thought. Next comes the series Questenberg — Neumann —
Gordon — Terzky, to which is added a number of other names,
this series being probably suggested by the expression " spat
komm ich " (I come late). At the end there follows the
digression into French, and then in the further course of the
letter fragments in English, Latin and Greek and a series of
high-sounding verses.

The handwriting of the patients may at first be quite
regular and correct. In consequence of the excitability,
however, it usually becomes gradually always larger, more
pretentious and more irregular. There is no more considera-

PSYCHIC SYMPTOMS

tion for the reader ; the letters run through one another, are
scribbled ; more words are underlined ; there are more marks
of exclamation ; the flourishes become bolder. All those

/../.^s;^ "^^^^^,,4r^;fe.c^'^c-}:ii,

Specimen of Writing.- — i. Mama.

disorders, those of substance as well as those of form, are well
shown in the accompanying specimen of writing. The
number of documents produced by manic patients is some-

36 MANIC-DEPRESSIVE INSANITY

times astonishing, though certainly they themselves do not
count on their being read ; the pleasure of writing itself is the
only motive.

Inhibition. — In the states of depression, in place of
pressure of activity inhibition of will, its complete antithesis,
generally appears. The performance of actions is here made
difficult, even impossible. The slighter degrees of the dis-
order are seen in the indecision of the patients. The emerg-
ing impulses are not strong enough to overcome the opposing
inhibitions ; in spite of clear recognition of necessity, al-
though all genuine motives to the contrary and reasons for
doubt are absent, the patient is yet not able to rouse himself
to carry out the simplest actions. He " has no longer any
will of his own," " does not know how he is to manage " ;
he must always ask advice about what he is to do ; he can no
longer do any thing rightly, as he is never certain that it is
the right thing. A patient said, "I'm a weak man, who
doesn't know what he wants."

The activity also, which after much hesitation is at last
begun, comes to a stop every moment, as the energj^ of vigour-
ous decision is lacking. The patient no longer finishes any-
thing, does everything the wrong way about, does not get any
further on in spite of all the work which he performs with the
greatest effort ; he has no right spring in him ; he is weighed
down with gloom. A female patient said that she had dressed
early intending to go out, and in the afternoon she was still at
home. All isolated movements, so far as the\^ require
volitional impulse, are carried out with more or less reduced
speed and without vigour ; hands and feet obey no longer.
The patient can no longer take hold of anything or keep hold
of it ; mouth and tongue are heavy as lead. His bearing is
relaxed and weary ; his behaviour stiff and constrained ; his
expression rigid and immobile.

In ergographic curves Gregor and Hansel were able to
demonstrate an abrupt and early fall of the curve, to which
followed low, long drawn-out curves, a sign of rapid failure of
voHtional impulse in prolonged exertion of muscles. Ex-
ternal influence, and especially pleasant excitement, may
decrease the inhibition. With steady persuasion or in danger
the patient is able to accomplish what otherwise would be
impossible for him. Often no parrying movements at all
follow pinpricks, or they only follow if very sensitive places
are pricked. Waxy flexibiUty and echo-phenomena are not
rare.

PSYCHIC SYMPTOMS

In the most severe stuporous forms every volitional ex-
pression of the patient may be arrested, so that he is only
able to He still and can scarcely open his eyes. He is unable
to show his tongue, to take his meals, to give his hand, or
even to leave his bed and relieve
nature. Although he perhaps under-
stands quite well what he is told to do,
yet at most a few weak, trembhng
attempts at the required movements
follow. The patient retains uncom-
fortable attitudes, because it is not
possible for him to change his position ;
all objects, which are placed in his
hand one after the other, he spasmod-
ically tries to hold, as he is incapable
of letting them go.

The extreme inhibition of even quite
simple volitional actions appears very
distinctly in the accompanying curve,
Fig, 8, of a reaction movement, which
Isserlin obtained from a depressed
patient. It should be compared with
the curves of normal individuals and of
catatonics given elsewhere.^ It shows
conclusively the extremely slow flexion
and extension of the finger and also the
small extent of the movement.

The inhibition of will is usually felt
as extremely painful by the patients.
The feeling of " insufficiency," of in-
capacity, is frequently already present,
when to outward observation no diffi-
culty at all in volitional actions can be
recognised. Very commonly the re-
mission in their work is interpreted by
the patients as a moral offence. They
reproach themselves most bitterly with
their inactivity ; they will not remain
in bed in order not to be thought lazy.
Many patients develop a convulsive mania for work, and
grudge themselves all rest in order to defend themselves from
their own reproaches. " The spade had to be taken out of

^ Kraepelin, Dementia Pycbcox and Paraphrenia. Translation Edinburgh,
p. 80 et seq. (Oct. 1919).

"El
S
c75

38 MANIC-DEPRESSIVE INSANITY

his hand for otherwise he did not stop," reported the relatives
of a patient. It is possible, however, that in such cases a
psychomotor excitement plays a part.

The difficulty in volitional discharge leads naturally to a
more or less considerable restriction of activity. Even if the
most necessary work is at first still performed, every spon-
taneous activity remains yet undone. The patients give up
their leisure occupations, and posts of honour, withdraw
themselves from society and continually feel the need of rest.
Later they neglect themselves and become careless. In the
end they give up every activity and take refuge in bed, where
they remain lying motionless, and in certain circumstances
even pass their motions there. Of practical importance is
the circumstance that the inability of the patients to come
to a decision lessens the danger of suicide in some degree, at
least at the height of the malady. Although they cherish
the fervent desire to put an end to their life, they yet have
not the power to carry out this intention. One of my
patients already stood in the water, but had not " the
courage " to jump in completely.

The various domains of volitional expression may be in-
fluenced in very different degree by volitional inhibition. As
primarily the discharge of volitional resolves appears to be
made difficult, those actions which are habitual and require
no interference of will are still done unhindered, while the in-
hibition makes itself very strongly felt in other domains.
The patients are able to dress themselves without difficulty
and to occupy themselves, while they are incapable of making
any independent resolve ; they still perhaps accompUsh
easily and habitually the work of the day without special
difficulty, but are alarmed at every new enterprise, at every
special responsibility.

Movements of expression, as far as they should reflect
psychic emotions, are usually attacked with special severity
by the inhibition ; mimic gestures also and movements
generally lose in vivacity. The patients speak in a low
voice, slowly, hesitatingly, monotonously, sometimes stutter-
ing, whispering, try several times before they bring out a
word, become mute in the middle of a sentence. They be-
come silent, monosyllabic, can no longer converse, although
they are able to count with customary rapidity or read aloud.
Sometimes they do not speak a word of their own accord, but
readily give information when asked, or they speak in a
whispering tone, but vehemently with vivacious gestures.

PSYCHIC SYMPTOMS 39

Pfersdorff has called attention to the fact, that many patients
make gross mistakes in speUing, omissions, duplications, ex-
changes of letters ; here it can occasionally be recognized
that associated clang-pictures influence the perception of the
visual picture {k instead of a or h). Copying is done in
certain circumstances unhindei'ed, while the patients sit for
hours before a letter, which they have begun, without bring-
ing it to an end. The disorder meantime does not affect
speech and writing at all in equal measure. There are
patients who speak quite fluently but can scarcely write a
few Hues, and vice versa others write long passionate letters,
while they become mute as soon as one wishes to con-
verse with them.

In the place of volitional inhibition anxious excitement
appears not very infrequently. The patients display a more
or less lively restlessness, cannot sit still, do not remain
in bed, run about, hide in corners, try to escape. They
whimper, groan, sigh, scream, wring their hands, tear out
their hair, beat their head, pluck at themselves and scratch
themselves, cHng to people, pray, kneel, slide about on the
floor, beg for mercy, for forgiveness. In severe cases it
comes to senseless screaming, lamenting, screeching, turning
and dancing about, snatching, twisting and twitching of the
hands and the trunk, rubbing and wobbKng. Frequently
monotonous, rhythmical repetition is conspicuous.

Specht, Thalbitzer, and also Dreyfus are inclined to inter-
pret that kind of anxious excitement from the point of view
of mixed states. It is said to be a case here of a 'con-
junction of depression with the manic morbid symptom of
volitional excitement. Taking the contrary view, Westphal
and Kolpin have pointed out that the excitement represents
an immediate outflow of anxiety, and therefore cannot be re-
garded as a manic component of the morbid state. To this
is may be replied that the anxiety in itself may produce in-
hibition just as well as excitement of volition ; it would be
therefore possible that the transformation of inward tension,
as we find it in many states of depressive stupor, into anxious
excitement, is facilitated or even caused by the appearance
of a volitional excitement in the sense of mania. It, how-
ever, appears to me hazardous to approach circumstances,
which are certainly very involved, with such simple con-
ceptions. We shall later meet with experiences which give
evidence that the peculiar, anxious colouring of the states of
depression, which completely differs from those of the manic

40 MANIC-DEPRESSIVE INSANITY

states, has a certain relation to age, a circumstance which
Specht, in fact, has made use of for his view. I consider it,
however, in the meantime very doubtful whether that
anxious excitement which occurs solely in the form of move-
ments of expression, though they may be of a very violent
and nonsensical kind, may without hesitation be conceived
as a mixture of anxious mood and manic pressure of activity
But on the other hand, as we shall later see, there are with-
out doubt states which are to be interpreted in this sense, and
it must be conceded that in certain circumstances the dis-
tinction will be difficult, that perhaps, indeed, transition
forms also may come vmder observation.

Pressure in Writing. — A good idea of the peculiarities
of the psychomotor disorders in manic-depressive insanity
is afforded by the accompanying curves, Fig. 9. They re-
present the pressure-oscillations in the writing of i and 10 in
a continuous series of figures. They were obtained with the
aid of a writing balance. The spaces on the horizontal Unes
give an idea of the time taken by the writing ; the height of
the curves represents on an enlarged scale the pressure
exercised each moment on the writing-table. Under the
individual curves there are accurate copies of the figures
themselves, as they were made in the experiments. Fig. A
comes from a healthy nurse. The remission of pressure
during the turning of the movement of writing and the rise
in the down-stroke are seen in the first i and still better in the
second ; in the o, also, a small pressure-oscillation corresponds
to the turning. The small curves at the end are caused by
after-oscillations of the pen on its being rapidly removed.

Fig. C was furnished by a female manic patient. The
psychomotor excitement appears here in the large pre-
tentious figures. The pressure is considerably raised and
also the speed of writing, if we take into account the different
length traversed by the pen. In the second i both pressure
and speed are raised very considerably, a phenomenon, which
also occurs in normal individuals everywhere, but which in
them is not nearly so marked. As it indicates to us the
increased facility of production during work, it may be re-
garded as an expression of increased psychomotor excita-
bility. The rapidly increasing number of after-oscillations
in the course of the writing points to the greater abruptness
of the pressure-oscillations in the violent movements of
writing.

A wholly different picture is presented by Fig. B, which

PSYCHIC SYMPTOMS

Fig. 9. — Pressure curves in writing in manic-depressive insanity.

42 MANIC-DEPRESSIVE INSANITY

was obtained from a patient in a state of depression. The
figures are remarkably small, in spite of which they re-
quired considerably longer time than Fig. A ; the speed was,
therefore, much less. At the same time the pressure is extra-
ordinarily low ; it does not even amount to 50 g., and the
oscillations are very slightly marked. After-oscillations are
absent ; the pressure of the writing therefore did not stop
abruptly but very gradually. Here also, moreover, a slight
increase of speed is seen in the second i. Between it and the
following o there is a disproportionately long pause. Accord-
ingly, as we found in the manic patient violent movements
very much accelerated with rapid and considerable increase
of excitability, so here we meet with hesitating commence-
ment and discontinuance, little vigour, and significant de-
crease in the speed of writing, signs which clearly indicate the
existence of a psychomotor inhibition.

But the two states of the instrument of our vohtion, which
are here distinguished from each other, are scarcely so
opposed to each other as might appear at first sight. We
see them at least in the course of the disease frequently
enough abruptly pass over the one into the other. In-
hibition and facilitation of volitional impulses may accord-
ingly be only nearly related phenomena of a common funda-
mental disorder. That becomes still more evident, when we
see that the symptoms of both the morbid changes not at all
infrequently are mixed. The special clinical forms of this
mixture we shall later have to examine more in detail.

Here I should like merely to refer to Fig D in the page of
curves. It is written by the same patient as Fig. C, only
she was then in a state, in which for a few days during a
severe attack of mania, the pressure of activity had com-
pletely disappeared. The figures are now smaller and the
pressure curve shows a slight decrease of pressure with slow
ascent and decline, and a very considerable decrease of speed,
thus an extremely peculiar mixture of the changes which we
have already learned to recognise in manic excitement and
in inhibition.

Certainly we do not by any means find everywhere such
marked changes of the pressure lines in writing. In especial
the investigations carried out hitherto to a somewhat greater
extent in states of depression have taught that here we find
the most manifold gradations of the forms of Fig. B to
approximately normal forms. Vigour, speed, and extent of
movement^in writing may not suffer any essential change

PSYCHIC SYMPTOMS 43

while the patients otherwise distinctly display the signs of
volitional, inhibition. It must for the present be left un-
decided whether the more severe disorders of writing are
peculiar to specially characteristic states, or are dependent
on the content of what is written, or on the greater or less
significance of the volitional impulses for the movement of
writing in individual persons.

CHAPTER III.

BODILY SYMPTOMS.

The attacks of manic-depressive insanity are invariably
accompanied by all kinds of bodily changes. By far the
most striking are the disorders of sleep and of general nourish-
ment. In mania sleep is in the more severe states of excite-
ment always considerably encroached upon ; sometimes

there is even almost com-
plete sleeplessness, at most
interrupted for a few
hours, which may last for
weeks, even for months.
In the slighter states of
excitement the patients go
late to bed and are also
very early wide awake,
but their sleep appears to
be extraordinarily deep.
In the states of depression
in spite of great need for
sleep, it is for the most
part sensibly encroached
upon ; the patients lie for
hours, sleepless in bed, tormented by painful ideas, and
after confused, anxious dreams awake the next morning
dazed, worn out and weary. They get up for the most part
very late ; they also perhaps remain in bed for days or
weeks, although even in bed they find no refreshment.

Appetite is in manic patients frequently increased, but
the taking of nourishment is nevertheless irregular in con-
consequence of haste and restlessness. In more severe mor-
bid states the patients frequently devour all possible in-
digestible and disgusting things ; they bolt their food without
due mastication, throw away the food that is offered them,
smear it about, spill it. Depressed patients have as a rule
little inclination to eat, and usually take nourishment only
with reluctance and with much persuasion. Their tongue is

Fig. io. — Body-weight during a
manic attack.

BODILY SYMPTOMS

coated and they suffer from constipation. Wilmanns and
Dreyfus have put forward the view, within certain Hmits
probably quite rightly, that so-called " nervous dyspepsia "
frequently represents merely an expression of the slightest

'Pj

'•)

/— \

--^y'

<^^

t
^

AV>

■^^

Fig. II. — Body-weight in long-continued mania.

states of depression. In-
dividual patients complain
from time to time, or else
continuously, of ravenous
appetite, which appears to
be a manifestation of anxiety.

The Body-weight always
falls very considerably in
acute mania, while in hypo-
manic attacks it rises as a
rule. An example of the
course of the body-weight
during an attack of severe
manic excitement, which
lasted about six months, is given in Fig. lo up to recovery.
With the advent of tranquillity the weight here rises with
very surprising rapidity, in one week 5 kg.

Fig. II shows a course extending over more than two

Fig. i:

-Great fluctuation of body-weight
in mania.

MANIC-DEPRESSIVE INSANITY

years. It is seen here that the lowest weight was already
reached in about six months. Although the manic excite-
ment from that time onwards lasted nearly a year in its
former severity, the weight yet rose with small fluctuations
steadily, and only in the last weeks remained constant, when
an irregular fluctuation between slight manic and depressive
moods had developed.

An essentially different picture is given by the curve re-
presented in Fig. 12. It comes from a manic patient, who
was discharged cured, perhaps a little depressed, after treat-
ment for ten months in the hospital ; he had already before
that been some months ill. We observe here before the last
rapid and considerable rise of the curve quite a number of
smaller oscillations of the weight, some of them fairly regular,
the highest points of which, however, remain far under the
height which was later reached. In general the fluctuations
of the psychic state corresponded to these oscillations, yet the
alternation of more excited and quieter periods appeared to
chnical observation far more irregular. The impression is
made here as though the whole attack had been composed of
a series of shorter single attacks, a phenomenon which is met
with not so very rarely. It cannot indeed specially surprise
us considering the frequent inclusion of variously coloured
attacks in one series, an occurrence which has given circular
insanity its name.

A somewhat divergent, but still for all that a similar
picture is seen in Fig. 13. Here it wa-- a c ase of manic excite-
ment, at first slight, then rapidly becoming more severe,

Fig. 13

-Body-weight during a compound
attack.

BODILY SYMI^TOMS

after which tranquilhty and transition to sUght depression
soon followed. To this period of the disease the first fall and
renewed rise of the
curve correspond. The
small descents which
now follow, and which
certainly are always
again compensated,
must render it doubtful
whether the attack had
already reached a close,
and indeed the com-
mencement of a severe
depressive state of
stupor appeared very
suddenly with a very
rapid fall of the body-
weight, which then was
followed by recovery.
We gather from this,
that in states of de-
pression also the body-
weight usually falls, and
this happens as a rule,
in contrast to mania, in
the slightest forms.

A peculiar example
of this is presented in
Fig. 14. Here there was
at first a slight, simple
state of depression,
which, with rise of the
body-weight, in about
three or four months
slowly but not com-
pletely improved. Then
followed immediately a
very severe depression
with extraordinary de-
lusions and hallucina-
tions, which in five
months led to complete recovery. To this attack, which
apparently at the time of discharge was not yet quite at an
end, the second large fluctuation of the curve corresponds.

48 MANIC-DEPRESSIVE INSANITY

In a very protracted course of states of depression, ex-
tending over a series of years I have repeatedly seen great
rise of the body-weight without any considerable improve-
ment of the psychic state. Recovery then followed much
later, occasionally after the weight had again fallen not in-
considerably and without a manic state being conjoined. An
indication of this behaviour can be recognised in Fig. 15,
where, in spite of very great increase of body-weight which
constantly remained high, there was yet no recovery. Much
rather was the psychic statt of the patient during this time
essentially worse than at the time of his discharge, which
happened later, when he weighed 4.5 kg. less.

General State. — Corresponding to the course of the
body-weight the general state of the patients usually ex-
periences striking changes. In the hypomanic periods the
skin acquires a fresh colour and tension ; the movements
become elastic and vigorous ; the scanty hair grows afresh,
even with renewed colour. In states of depression on the con-
trary, the skin becomes pale, wrinkled, withered, dry, rough ;
the eye becomes dull ; the growth of the nails stops and
becomes irregular, as Falcida has demonstrated ; the menses
become scanty or intermittent ; the secretion of tears dries
up ; the whole being appears prematurely old.

All these changes indicate that in manic-depressive in-
sanity marked disorders of metabolism must take place. Un-
fortunately the results of investigations carried out in regard
to this have been up till now still rather unsatisfactory.
Mendel found in mania a decrease of phosphorus in the
urine, while Guerin and Aime found the excretion of lime and
magnesia increased ; in states of depression that is said to be
diminished. On the other hand Seige was not able to
demonstrate any abnormahty in the metabolism of minerals.
He observed in melanchoHa a strong tendency to the storage
of nitrogen, which then is suddenly excreted in increased
quantity. The endogenous excretion of uric acid, according
to his statements, remains in depressive patients at the lower
limits of the normal, whereas in manics it is reduced. Here
it appeared to be a case of abnormally rapid breaking down
of the purin bodies to still lower stages of disintegration.
Lange has arrived at the opinion, that increased formation of
uric acid may be regarded as the essential cause of states
of depression. Raimann was able to establish that in states
of depression aUmentary glycosuria could be produced.
Schultze and Knauer hkewise were able to demonstrate that.

BODILY SYMPTOMS 49

as in other forms of psychic disease so also in the states of
manic-depressive insanity, ahmentary glycosuria appeared,
probably as a consequence of anxiety ; it was found with
special frequency in depression (67%), more rarely in
mixed states (53%), and in mania (19%). Now and then
diabetes insipidus is observed ; in older patients I often saw
continuous excretion of sugar. The reducing power of the
urine was found by Pini raised in general, especially in mania,
on the other hand lowered in long-continuing states of ex-
citement.

Albert! investigated the toxicity of the urine and blood-
serum, without obtaining any useful results. Pilcz was able
fairly frequently to establish the appearance of all kinds of
abnormal substances in the urine, acetone, diacetic acid,
indican, albumose, which re-appeared in the attacks of the
same patients, but without any definite relation to the colour-
ing of the mood being recognised. Taubert found indican-
uria in mania, often one or two days before the outbreak of
excitement, while Seige observed indican disappear almost
completely from the urine in excitement. On the other hand
he observed in a depressed patient an unusually great ex-
cretion of indican, which began already two days before the
transition from the former manic excitement and which was
not accompanied by constipation. Townsend also was able
to demonstrate an increased indoxyl excretion, which in
states of depression was specially strongly marked, and which
began to disappear shortly before the appearance of psychic
improvement. Apparently it is here everywhere a case of
the consequences of intestinal disorders which are so frequent
in manic-depressive insanity. Hannard and Sergeant found
in states of depression frequent cholsemia.

Blood - Picture.— The investigations of blood which
Fischer carried out in five manic patients did not yield any
characteristic change. The haemoglobin content and the
number of red blood corpuscles were frequently increased,
the number of the white almost always, perhaps in con-
sequence of the constant excitement. Dumas reports a
decrease in the red blood corpuscles in the beginning of
mania, an increase at the beginning of depression, changes
which are said to be occasionally reversed in the further
course of the attacks. The haemolytic resistance of the red
blood corpuscles in the presence of the serum of other patients
or of normal individuals was found by Alberti to be weakened
in mania, fluctuating in states of depression. Parhon and

50 MANIC-DEPRESSIVE INSANITY

Urechie in both periods of the disease observed increase of the
mononuclear leucocytes.

Circu ation. — The changes in the behaviour of the cir-
culatory organs are often specially striking. Fairly fre-
quently there are found murmurs at the heart, extension of
cardiac dulness, increased excitability of the heart, tendency
to congestion, erythemata, great perspiration, dermography.
In manic patients the face is often flushed, the conjunctivae
injected. I once saw, in consequence of continued screaming,
extreme swelhng and tortuosity of the superficial veins of the
neck. In states of depression the complexion is usually pale
and grey ; the lips often appear shghtly cyanotic, the hands
and feet cold, pale or livid. Not very infrequently one ob-
serves indications of Basedow's phenomena, a soft swelling of
the thyroid gland with acceleration of the pulse, tremor and
abundant perspiration, now and then also occasional ex-
ophthalmos. Not at all infrequently and in comparative
youth arteriosclerosis is present.

About the behaviour of the pulse-rate and the blood-
pressure statements are very divergent. It is usually
assumed that in mania the pulse is accelerated, in melan-
choUa retarded. The investigations carried out by Weber
in our hospital gave on the contrary a raised pulse-rate in
states of depression, especially in those with excitement ; in
lively manic excitement a similar result was found, while in
quieter manic patients the frequency of the heart-beat was
frequently shown to be normal and even somewhat retarded.
The blood-pressure was found by Pilcz to be lowered in
mania, raised in melancholia, while Falcioli observed it fall in
states of depression and only rise on the appearance of
anxiety. In mania, in consequence of the rapid and ex-
tensive widening of the vessel, one observes at each heart-
beat pulse waves with rapidly rising, sharp, steeply-falling
summit and distinctly marked dicrotism. In depressed
patients, on the other hand, because of the raised tension there
are low and sluggish pulse waves with slightly raised or
rounded summit and feeble dicrotism.

The investigations of Weber carried out with newer and
more perfect instruments confirmed the rise of blood-pressure
in states of depression ; it was greatest in depressive excite-
ment. On the other hand it was shown that also in mania,
especially in more severe excitement and in manic stupor, it
is frequently raised. The behaviour of pulse and blood-
pressure at the same time usually corresponds fairly closely

BODILY SYMPTOMS

to the changes in the psychic state. A picture of this is given
in Fig. i6, in which besides pulse-rate and blood-pressure,

to
<a

u
C,

1
i

-^'

-4

/
/

}

•

,ji

;

/
1

\ 1

f 1

•?

'S"

/ ^

N 1

\ :?>

/ 1

/ V.

/ 1

\ ::

\fe

6 -* vS \

5i !?

%
^

^
■*

> ^

fe «

which at the times indicated below were investigated by
means of the Recklinghaus method, together with the hori-

52 MANIC-DEPRESSIVE INSANITY

zontal lines indicating the normal average values, the course
of the body-weight is also reproduced. It is seen how pulse
and blood-pressure, after fluctuations at the beginning,
gradually return to normal with the rise of body-weight,
which accompanies the improvement in the general state.

Respiration is accelerated in states of excitement, re-
tarded in simple depression and in stupor ; in great anxiety
interrupted or jerky breathing is occasionally observed.
Vogt found the fluctuations of respiration on the plethysmo-
graph curve specially marked in manic patients ; in more
severe depression they were also invariably present.

Temperature is occasionally high-normal in violent
excitement, and often lowered in severe states of depression.

The Menses at the beginning of the attack frequently
stop for some time, especially in depressed patients, and
return on the approach of recovery, occasionally as the first
sign of it. Not infrequently during the menses aggravation
of the morbid phenomena is observed.

" Nervous " Disorders of all kinds usually appear,
especially in depressed patients. Apart from the headaches
already mentioned and the manifold dysaesthesiae, the
patients complain about tiredness, feelings of oppression,
noises in their ears, palpitation, shivering in the back, heavi-
ness in the limbs. The tendon reflexes are frequently in-
creased. Weiler found in general a steeper rise of the reflex
curve, shortening of the reflex time, and powerful brake-
action of the fall. In deep depression and in states of stupor
the extent of the reflex decreased ; in the latter the reflex
time was lengthened. The pupils are, according to Weiler's
statements, somewhat frequently dilated, but otherwise show
no deviations worth mentioning.

In many patients special sensitiveness to the influence of
weather seemed to me to exist ; they felt lively discomfort for
a considerable time on the approach of thunder-storms.

Of special importance is the fact that in our patients dis-
orders are extraordinarily often observed, which we usually
call hysterical. Here belong above everything fainting fits
and attacks of giddiness, as well as fully developed hysterical
convulsions, further, choreiform clonic convulsions, psycho-
genic tremor, singultus, convulsive weeping, somnambulism,
abasia. Decrease in the pharyngeal and conjunctival re-
flexes, disorders of sensation of various nature, namely
analgesia, patella and ankle clonus are also found. Many
delirious states, which run a rapid course with dulling of

BODILY SYMPTOMS 53

consciousness, appear to have an hysterical colouring, as
Imboden has emphasised. A female patient, who became
manic after the death of her lover, wandered aimlessly about
for some days in order to look for her dead " Toni," and had
only a very dim recollection of this journey. Another
asserted that she had been surprised and overpowered, but
then stated that she could not say definitely whether it had
not been a dream. In spite of the very imperfect information
which was forthcoming about these morbid symptoms, they
were proved in 13-14% of the men, and in about 22% of the
women, by preference at the younger ages.

In a few cases also attacks of epileptic nature were noted,
some of them being observed by ourselves. Lastly organic
disorders appeared now and then especially among the men
and at a more advanced age, apoplectic attacks with or with-
out subsequent paralysis, transient loss of speech, cortical
epileptic attacks. For the most part it was here a case of a
conjunction with arteriosclerosis, often also with lues.

CHAPTER IV.
MANIC STATES.

The presentation of the individual clinical states, in which
manic-depressive insanity usually appears, will in the first
place have to begin with the conspicuous contrasts between
manic and depressive attacks. With these are associated,
as third form, the mixed states which are composed of states
apparently the opposite of each other. Lastly, we shall have
to consider the inconspicuous changes in the psychic life
which continue even in the intervals between the marked
attacks, changes in which the general psychopathic foundation
of manic-depressive insanity comes to expression. It must,
however, be emphasised beforehand that the delimitation of
the individual clinical forms of the malady is in many respects
wholly artificial and arbitrary. Observation not only reveals
the occurrence of gradual transitions between all the various
states, but it also shows that within the shortest space of
time the same morbid case may pass through most manifold
transformations. The doctrine of form given here may
accordingly be regarded as an attempt to set in order quite
generally with some degree of lucidity the mass of material
gathered by experience.

Hypomania.

The slightest forms of manic excitement are usually
called " hypomania," mania mitis, mitissima, also, but
inappropriately, mania sine delirio. The French have
spoken of a " folic raisonnante," an insanity without
disorder of intellect. Indeed the sense, the power of per-
ception, the memory of the patients, appear in general not
disordered. Psychic activity, mobility of attention, are not
infrequently even increased ; the patients may appear
hveher, more capable than formerly. In especial the abiUty
to perceive distant resemblances often surprises the hearer,
because it enables the patient to produce witty remarks and
fancies, puns, startling comparisons, although usually not

MANIC STATES 55

very valid when examined more minutely, and similar pro-
ducts of the imagination. Nevertheless even in the slightest
degrees of the disorder the following features are extra-
ordinarily characteristic, the lack of inner unity in the course
of ideas, the incapacity to carry out consistently a definite
series of thoughts, to work out steadily and logically and to <
set in order given ideas, also the fickleness of interest and the
sudden and abrupt jumping from one subject to another.
Certainly the patients are not infrequently able with some
effort to overcome temporarily these phenomena and to gain
the mastery again for some time yet over the course of their
ideas which have become unbridled. In writing and especi-
ally in rhyming, which is often diligently indulged in, a slight
flight of ideas usually makes a distinct appearance. But
even in these slight forms fairly severe excitement and con-
fusion may temporarily be present.

Recollection of recent events is not always exact, but
is often coloured and supplemented by original additions.
The patient is easily led away in his narrations to exaggera-
tions and distortions, which arise partly from mistaken
perception, but partly also from subsequent misinterpretation
without the arbitrariness of it coming clearly into his con-
sciousness. Although genuine delusions are absent we in-
variably meet with a very much exaggerated opinion of self.
The patient boasts about his aristocratic acquaintances, his
prospects of marriage, gives himself out as a count, as a
" doctor because of his services to the state," wants " to have
everything magnificent," speaks of inheritances which he
may expect, has visiting cards printed with a crown on them.
A lady signed her letters " Athene ". A lay-sister narrated
that a miracle happened at her birth, that she had super-
natural gifts and would reform the order. In eloquent
words the patient boasts of his performances and capa-
bihties ; he understands everything best ; he ridicules the
doings of others with aristocratic contempt, and desires
special recognition for his own person. He is an " excellent
poet, orator, jester, and man of business ", a " jolly fellow " ;
he can work like a nigger, can take the place of many a pro-
professor or diplomatist. A patient, who was charged with
begging, declared proudly, " The beggar is the true king."

Insight. — Of this there is as a rule no question ; even by
a reminder of former attacks, of which during depression the
patient perhaps formed a quite correct opinion, he cannot for
a moment be convinced of the real nature of his state. On

56 MANIC-DEPRESSIVE INSANITY

the contrary he feels himself healthier and more capable than
ever, has " a colossal energy for work ", is " awfully merry ",
at most is somewhat excited by the unworthy treatment. The
restriction of his freedom he regards as a bad joke, or as an
unpardonable injustice, which he connects with the perverse
ongoings of his relatives or of persons otherwise inimical to
him, and he threatens to take legal measures for their re-
moval and punishment. Those, not he, are mentally
afflicted, who did not know how to appreciate his intellectual
superiority and his gifts, an4 who tried to excite him by
irritating and provoking him. This behaviour reminds one
of the experiences so frequently encountered of the self-
deceptions of drunkards.

Mood is predominantly exalted and cheerful, influenced
by the feeling of heightened capacity for work. The patient
is in imperturbable good temper, sure of success, " courage-
ous," feels happy and merry, not rarely overflowingly so,
wakes up every morning "in excellent humour". He sees
himself surrounded by pleasant and aristocratic people, finds
complete satisfaction in the enjoyment of friendship, of art,
of humanity ; he will make everyone happy, abolish social
wretchedness, convert all in his surroundings. For the most
part an exuberant, unrestrained mood inchned to practical
jokes of all kinds is developed. Occasionally there is
developed a markedly humorous trait, the tendency to look
at everything and every occurrence from the jocular side, to
invent nicknames, to make fun of himself and others. A
patient called himself a " thoroughbred professional fool " ;
another declared the hospital was a " nerve-ruining in-
stitution " ; a third stated that he was a " poet, cattle-driver,
author, tinker, teacher, popular reformer, chief anarchist and
detective ". On the other hand there often enough exists a
great emotional irritability. The patient is dissatisfied, in-
tolerant, fault-finding, especially in intercourse with his
immediate surroundings, where he lets himself go ; he
tfecomes pretentious, positive, regardless, impertinent and
even rough, when he comes up against opposition to his
wishes and inclinations ; trifling external occasions may bring
about extremely violent outbursts of rage. In his fury he
thrashes his wife and children, threatens to smash every-
thing to smithereens, to run amuck, to set the house on fire,
abuses the " tribe " of his relatives in the most violent
language, especially when under the influence of alcohol.
The internal equihbrium of the patient is lost ; he is led wholly

MANIC STATES 57

by momentary impressions and emotions which immediately
obtain mastery over his mood and his excited voHtion. His
actions accordingly often bear the stamp of impulsiveness,
lack of forethought, and— because of the slight disorder of
intellect — of immorality.

Increased Busyness is the most striking feature. The
patient feels the need to get out of himself, to be on more
intimate terms with his surroundings, to play a part. As he
is a stranger to fatigue, his activity goes on day and night ;
work becomes very easy to him ; ideas flow to him. He
cannot stay long in bed ; early in the morning, even at
four o'clock he gets up, he clears out lumber rooms, discharges
business that was in arrears, undertakes morning walks, ex-
cursions. He begins to take part in social entertainments, to
write many long letters, to keep a diary, to go in a great deal
for music and authorship. Especially the tendency to
rhyming (letters !) is usually very conspicuous. A simple
peasant published his rhymes made up of flights of ideas
himself. A young lady on her departure from the institution
composed a humorous testament in doggerel and had it
printed.

His pressure of activity causes the patient to change about
his furniture, to visit distant acquaintances, to take himself
up with all possible things and circumstances, which formerly
he never thought about. Politics, the universal language,
aeronautics, the women's question, public affairs of all kinds
and their need of improvement, give him employment. A
physician advertised lectures about " original sin. Genesis,
natural selection and breeding." Another patient drove
about in a cab and distributed pictures of the saints. The
patient enters into numerous engagements, suddenly pays all
his business debts without its being necessary, makes magni-
ficent presents, builds all kinds of castles in the air, and with
swift enthusiasm precipitates himself in daring undertakings
much beyond his powers. He has 16,000 picture post-cards
of his little village printed, tries to adopt a negro boy from the
Cameroons. A patient made a sudden offer to the police to
produce on the spot immediately a political criminal who had
been long sought for, at the same time lending the official a
fancy uniform as a joke, and by an advertisement in the news-
paper he invited " the whole Hautevolee " to a ball in a little
outlook tower.

At the same time the real capacity for work invariably
suffers a considerable loss. The patient no longer has any

58 MANIC-DEPRESSIVE INSANITY

perseverance, leaves what he begins half finished, is slovenly
and careless in the execution of anything, only does what he
likes, neglects his real duties. A patient spent his whole time
in plans for marriage, reading the newspapers, going walks,
and playing bowls. " He is over-busy," was said of another,
" but accomplishes less than formerly." Just as it occurs
to him, the patient undertakes unnecessary journeys,
wanders about, takes drives, pawns his watch, borrows
money, makes useless purchases and exchanges, even when
he has not a penny in his pocket, because every new object
stimulates his desire. Even occasional theft and fraud are
sometimes committed in this morbid lust for possession in
order to obtain what is desired. A patient emphatically
demanded a rise of salary, and at the same time threatened
to give the alarm to the fire brigade in order to draw people's
attention to his condition. A female patient gave over-weight
in business ; another drank other people's glasses empty.

External Behaviour. — Exalted self -consciousness, the
passion to come to the front, is conspicuous, and also restless-
ness and changeableness. The patient dresses contrary to
his usual custom, according to the newest fashion, though
perhaps negligently, wears " a hat hke Bismarck," sticks
flowers in his button-hole, uses perfume galore. A female
patient had her hair dressed eleven times in succession. The
patient everywhere leads the conversation, interferes, forces
his way to the front at every opportunity, in spite of deep
mourning takes part in noisy entertainments, recites in public,
subscribes largely to collections, tries to turn all eyes to him-
self, to make an impression, indulges in pecuharities. A
patient described himself as " a conglomerate of all passions,
sadist, masochist, fetishist, onanist".

He often makes himself conspicuous by all sorts of dis-
orderly conduct ; he serenades with trumpets, spends the
night on benches out of doors, promenades in a dress coat wear-
ing an order made by himself, takes a bath with his clothes on,
performs military exercises with a broom, goes about the
streets distributing blessings, pays a visit to the archbishop
without any occasion. A female patient imitated an
hysterical attack ; another acted a little scene from a drama,
apparently gave all sorts of domestic directions, telephoned
for meat, quarrelled with the telephone girl, expressed her-
self very indignantly about the girl's alleged negligence ; a
third read aloud from the newspapers all sorts of invented
nonsensical things.

MANIC STATES 59

In company the patient behaves without ceremony, is
guilty of offences against decency and morahty, tells risky
jokes before ladies, carries on boastful conversations, in
wanton merriment behaves with unsuitable familiarity to-
wards strangers or his superiors, is friends with the first
person he meets and calls him by his first n,ame. A peasant
girl began to charge the people in her surroundings with all
their "wrong-doings," especially her .companions, with
illegitimate children. In consequence of his petulance and
irritabihty the patient frequently comes into conflict with
his surroundings and with the authorities ; he insults officials,
demands from the physician satisfaction as a cavalier, runs
up debts in public houses, is called to account by his superiors
and brought to order. A school-boy, who had a quarrel with
some peasants, challenged them with pistols, handed them
his card, and then fired a shot in the air ; he threatened to
shoot his headmaster, who had inflicted a punishment on
him. Many patients become involved in law-suits which
they carry on with great passionateness in the most correct
forms through the highest courts of appeal. Because of their
comprehensive petitions teeming with self-consciousness,
affronts, and bold assertions, they are easily taken for litigants,
till with the appearance of tranquillity or even the transition
to depression, they repentantly beat a retreat.

The tendency to debauchery usually becomes especially
fatal to the patients. He begins to get drunk frequently, to
gamble foolishly, to remain out at night, to frequent brothels
and doubtful taverns, to smoke and snuff excessively, to eat
strongly-seasoned food. When such states of excitement
occur frequently, and are of short duration, a picture very
similar to dipsomania may arise.

Sexual Excitability experiences a considerable in-
crease. An elderly father of a family, who otherwise lived a
very retired life, began to drink champagne with the girl
fencers from a circus. Another tried to force his way into the
cook's room, and when he was found fault with, excused him-
self with his " midsummer madness." Women begin to
dress conspicuously, to wear false hair, to put on style, to
carry on equivocal conversations, to go to balls, to be frivol-
ous, to enter into love-affairs regardlessly, to read indecent
novels. A young girl pawned her clothes in order to procure
a fancy dress and go to a ball with a gentleman who was a
stranger to her. A woman handled the genitals of her six-
teen-year-old son and threw back the coverings of the journey-

6o MANIC-DEPRESSIVE INSANITY

man who was lying in bed. Another female patient, when in
this state, invariably made proposals of marriage, which in
the end had the result that, with the help of an agent, she
actually did enter into marriage with a man not at all trust-
worthy. A married lady in each manic attack conceived a
violent passion for any male person in her surroundings,
finally with a man, thirty years her junior, and in every
respect very much her inferior, and she overwhelmed her
beloved with the most fervid declarations of love in spite
of his unresponsive attitude. Another began to write
bombastic verses about a teacher. A servant-girl harassed
a captain in the army with numerous love-letters, which she
signed " your fiancee," and she tried in every way to force
herself into his presence. Incomprehensible engagements,
also pregnancies, are not rare in these states. I know cases
in which the commencement of excitement was repeatedly
announced by a sudden engagement. " Each child has a
different father," declared a female patient. From these
proceedings serious matrimonial quarrels naturally arise. A
woman declared that she was going to commit adultery in
order to get a divorce from her husband. Others become
jealous and assert that their husbands keep company with
innumerable females, and on this account want to shut them
up in the asylum.

Rationalisation by Patients. — With extraordinary
acuteness the patient can find a reason for all his astonishing
and nonsensical doings ; he is never at a loss for an excuse or
explanation. The exertions of his relatives to quiet him are,
therefore, not only ineffectual, but they only irritate him and
easily lead to violent outbursts of rage. In the institution
the patient usually presses for discharge from the first day,
gives as exclusive cause of his violence the unjust deprivation
of freedom, declares off hand that the physicians are " crazy,"
reproaches them with their incapacity, and demands to be ex-
amined by other authorities. One of my patients succeeded
in persuading his wife to transfer him against my advice to
another institution. On the journe}', which was qpite short,
he himself took the lead, drove away from his wife, and went
to Berlin to have himself examined by a physician who had
obtained a certain reputation for certifying mentally unsound
people as sane.

Movements of Expression arc as a rule lively and
passionate. The patients talk a great deal, hastily, in loud
tones, with great verbosity and prolixity, jumping from one

MANIC STATES 6i

subject to another, using sought-out, bombastic expressions,
speaking with pecuHar intonation, and of themselves often in
the third person in order to place themselves in the right light.
Silly joking, puns, violent expressions, quotations, scraps of
foreign languages play a large part, and occasionally violent
abuse and swearing or emotional weeping intervenes. Their
writing displays large, pretentious flourishes, many marks of
exclamation and interrogation, underlining, besides neglig-
ence in the external form. Many patients compose bombastic
or humorous documents full of flights of ideas and irritation,
in which they narrate without reserve all their family affairs,
beg for certificates of sanity, and call for the protection of
public opinion.

The variety in detail of this state is, in spite of all the
common features, very large. The more slightly the real
morbid process affects the individual, the more conspicuous
are his personal peculiarities in the form which the mani-
festations assume. The differences are noticeable especially
in the kind and intensity of the emotions. While many
patients at this time are amiable, good-natured, docile,
sociable, and at most become disturbing to their surround-
ings by their restlessness, others because of their irritability,
their imperiousness, and their regardless pressure of activity,
are extraordinarily difficult and unpleasant. It is just the
peculiar mixture of sense and maniacal activity, frequently
also an extensive experience of institutions, which makes
them extremely ingenious in finding out means to satisfy
their numerous desires, to deceive their surroundings, to pro-
cure for themselves all kinds of advantages, to secure the
property of others for themselves. They usually soon
domineer completely over their fellow-patients, use them for
profit, report about them to the physician in technical terms,
act as guardian to them, and hold them in check.

Acute Mania.

From the slighter forms of mania here described,
imperceptible transitions gradually lead to the morbid
state of actual acute mania. The beginning of the illness
is always fairly sudden ; at most headaches, weariness,
lack of pleasure in work or a great busyness, irritabihty,
sleeplessness, precede by some days or weeks the outbreak of
the more violent manifestations, when a definite state of
depression has not, as is very frequent, formed the prelude.
The patients rapidly become restless, disconnected in their

62 MANIC-DEPRESSIVE INSANITY

talk, and perpetrate all sorts of curious actions. They run
out of the house in a shirt, go to church in a petticoat, spend
the night in a field of corn, give away their property, disturb
the service in church by screaming and singing, kneel and
pray on the street, fire a pistol in a waiting-room, put soap
and soda in the food, try to force their way into the palace,
throw objects out at the window. A female patient jumped
into the carriage of a prince for a joke. Another rang a
chemist's bell at night, as she alleged that she had been
poisoned. A third went to the physician at his consulting
hour in her ball-dress, and to church similarly dressed. A
male patient appropriated the property of others in taverns.
Another appeared in the court of justice in order to catch a
murderer. Yet another asserted that he was on the track of
an anarchist plot.

As a rule, therefore, the patients must be brought to an
institution in a few days. Here they show themselves
sensible and approximately oriented, but extraordinarily
distractible in perception and train of thought. Sometimes
it is quite impossible to get into communication with them ;
as a rule, however, they understand emphatic speech, and
even give isolated suitable replies, but they are influenced by
every new impression ; they digress, they go into endless
details, in short, they display more or less developed flights of
ideas, as we have already described minutely.

Delusions. — Very commonly fugitive delusions are ex-
pressed, usually more in a jocular way. The patient asserts
that he is descended from a noble family, that he is a gentle-
man ; he calls himself a genius, the Emperor William, the
Emperor of Russia, Christ ; he can drive out the devil. A
patient suddenly cried out on the street that he was the Lord
God ; the devil had left him. Female patients possess eighty
genuine diamonds, are singers, leading violinists. Queen of
Bavaria, daughter of the Regent, Maid of Orleans, a fairy ;
they are pregnant, are going to be engaged to St Francis, are
to give birth to the Redeemer of the Jews, the Messiah. St.
Joseph lay beside them in bed ; the pope and the king came
to them ; Christ Hves in them again. A female patient
asserted that she was the Christchild and was three years old.
The patients are often disoriented about their own position
and their place of residence ; they make mistakes about
persons, often in a playful way. Now and then isolated
hallucinations are reported. The patients see horsemen in
the clouds, saints, a dead child ; they carry on a conversation

MANIC STATES 63

with their father who is dead, with the Virgin Mary ; they
feel themselves influenced by something external.

Occasionally the patients narrate all sorts of extra-
ordinary adventures. A female patient asserted that she
had been assaulted and abused, but then said that she could
not swear that it had not been a dream. Many patients have
a certain morbid feeling, and at times make fun of the ideas
which they bring forward. Great wishes and plans are also
developed. The patient wishes to invent something, to buy
houses, to marry a professor's daughter with a large dowry,
to go to the university ; he has already a doctor's degree.
He hopes to get his whole breast covered with orders, wishes
to cure patients by hypnosis, will see to it that everyone goes
to heaven, and that the penal code will be reformed according
to religious principles. A female patient desired to buy a
bicycle " decorated with lilies " ; others demand diamond
earrings, expensive clothes.

Mood is unrestrained, merry, exultant, occasionally vision-
ary or pompous, but always subject to frequent variation,
easily changing to irritability and irascibiltiy or even to
lamentation and weeping. Such, fluctuations of mood are
very clearly seen in the following letter of a manic patient : —

" When I think of my rude behaviour towards you at the last visit, I do
not know how I am to atone for it. I ask you for pardon from my heart ;
as far as it hes in my power, such a thing will never occur again. As I now
understand, I should have given you an answer and I did not do so. O
God, how discourteous ! |

" So gern mocht ich nun off en sein,

Doch langst hab' ich's gefiihlt,

Dass niemand mich versteht, allein,

Nur ich empfind', wie's wiihlt. *

Das Leiden, das ich hab' in mir,

O Gott, ich frag', warum.

Das weisst Du nicht, ich gab es Dir.
"And you still ask so stupidly. Whom the Lord loveth, he chasteneth.
Thy will be done. ] And when the Lord chasteneth ! Then he pierces !
But I must stop. — I The sky is blue ! The weather is beautiful ! Pro-
fessor, I should like to take a walk. If it is not good for me, I shall obey."

At the places marked a new page began ; of the contents
of the first about the half has been left out as unessential.
One notices how the penitent contrition, which appeared after
a violent state of excitement, is on the second page diverted
by the interruption made by turning the leaf to another
depressive circle of ideas, but how immediately now, in the
rhyme and also in the self-derision at the end, manic excite-
ment is conspicuous. From here onwards the calligraphy
begins to be fantastic, large and pretentious, so that the few

64 MANIC-DEPRESSIVE INSANITY

following words with their frequent marks of exclamation and
interrogation cover the whole side. At the same time the
train of ideas vacillates from religious ideas to the blue sky
and in rhyming to taking a walk. [Several of the words
rhyme in German.] The concluding words are obviously
quieter and are added in smaller writing.

At the most trifling affront it may come to outbursts of
rage of extraordinary violence, to veritable high-tides of
clamorous abuse and bellowing, to dangerous threats with
shooting and stabbing, to blind destruction and actual
attacks. The female sex has a much greater tendency to
such outbursts than the male sex. Sexual excitement finds
an outlet in obscene talk, forcible approach to youthful
patients, shameless masturbation ; among the female patients
in calling the physicians by their first names, dressing up,
taking down their hair, anointing themselves with saliva,
frequent spitting, using indecent and abusive language, as
well as in sexual calumniation of the nursing staff. A female
patient made signs to the soldiers from the window.

Conduct. — The behaviour of the patients is, as a rule,
free and easy, self-conscious, unmannerly or confiding, im-
portunate. They run after the physician, are always inter-
rupting, let themselves be diverted or influenced by per-
suasion, imitate other patients, and not rarely display
indications of automatic obedience ; they do not defend
themselves from pricks. But often enough they are re-
pellent, pert, imapproachable ; they resist, hide in comers,
close their eyes, hold their fingers before their face in
order .to blink- through them. Many patients obey no
directions, act on purpose the wrong way about. A female
patient in greeting gave her index finger, another gave her
foot instead of her hand. The morbid picture is dominated
by the rapidly increasing volitional excitement, which in its
impulsiveness and suggestibility may remind one of alcoholic
poisoning. A female patient behaved herself according to the
description given by her neighbours " like a drunken man ".

The patient cannot sit or lie still for long, jumps out of bed,
runs about, hops, dances, mounts on tables and benches, takes
down pictures. He forces his way out, takes off his clothes,
teases his fellow-patients, dives, splashes and squirts in the
bath, romps, boats on the table, bites, spits, chirps and clicks.
These vohtional utterances in general usually exhibit the
stamp of natural activities and movements of expression,
although frequently mutilated and over-hasty. Among

MANIC STATES 65

these, however, are frequently interpolated movements
which can only be regarded as discharges of inner restless-
ness, shaking of the upper part of the body, waltzing about,
waving and flourishing the arms, distorting the limbs, rubbing
the head, bouncing up and down, stroking, wiping, twitching,
clapping and drumming. Sometimes these movements are
conspicuously clumsy and inelegant, or affected and peculiar.
Not at all infrequently they are carried out rhythmically,
also perhaps for a considerable time they are continued
monotonously. Similarly the patients are heard now and
then repeating for hours the same phrases and laughing to
themselves. Not rarely they are dirty, pass their motions
under them, and smear things with their evacuations.

Many patients display a great tendency to be destructive.
They sht up their suits and bed-clothes in order to use the
rags knotted and twisted in a hundred ways for extraordinary
decorations. All objects in any way attainable are broken
up into their component parts, in order to be put together
again as new structures of various kinds, according to the
uispiration of the moment. Buttons are twisted off, pockets
torn out, the coat is turned inside out, the trousers are stuck
in the stockings, the ends of the shirt are knotted together,
rings made of remnants of yarn or destroyed shirt buttons are
forced on to the fingers, cuffs and collars are manufactured
from paper. Whatever falls into the hands of the patient,
stones, little bits of wood, broken pieces of glass, nails, he
collects in order by means of them to scratch walls, furniture,
and windows and to cover these in all directions with
paintings or writing. Remains of cigars and withered leaves
are wrapped in paper and smoked ; scraps of paper are used for
writing, nails for filling pipes, and shards for sharpening lead-
pencils. Other things found are used for barter in order to
obtain small advantages from fellow-patients. Occasion-
ally all sorts of things are stuck in the nose and ears ; the lobes
of the ears are pierced with matches or little bits of wire ;
ashes and dust are used as snuff ; the beard is partially
singed with the cigar.

Movements of Expression are for the most part very
vivacious. The patient makes faces, rolls his eyes, assumes
theatrical attitudes, stands erect, salutes in mihtary fashion.
He usually produces in the shortest interval of time an
enormous flood of words with changing intonation, makes
jokes, is quick at repartee, swears, scolds, suddenly makes a
noise, recites, preaches, mutters to himself, and now and

66 MANIC-DEPRESSIVE INSANITY

again screams out loud. He bellows, sings music-hall songs,
hymns, often for hours the same, prays, imitates the sounds of
animals, calls out hallelujah ; among these are interpolated
roaring, whistling, yodehng, shouting, uncontrollable laughter.
But at times, even in spite of lively excitement, the patients
may be taciturn ; they do not reply to questions or they give
short and evasive answers ; they perhaps only make a few
expressive gestures and then suddenly break out with the
greatest vivacity. Jocular speaking past the subject also
occurs now and then, right instead of left, six instead of five.
A female patient always repeated the question directed to
her ; another persistently replied, " How ? " ; a third, " I
don't know that ". Associations with external impressions
and rhyming frequently occur in the conversation of the
patients. A female patient called out to the physician, " Du
bist allerhand — Kraut und Riiben durcheinand ". In more
severe excitement the utterances may become quite dis-
connected as the following notes show : —

" On the most real of all grave — i, 2, 3, and always, always in the
greatest of all row — in the pancake — Elsie — by the grace and mercy of
God, by all reality might one 1 7 incomprehensible little graves of thought
— taken from the highest of all slender little grave — no Provisor believes
that — and always again for a Siegfried or assessor — Professor in an
extended — So was it and not otherwise — I can't help it — i, 2, 3 Francisca
B. it was — no, that one must no longer of a Professor — a, b, c — in all reality
— most real first of all state trumpet . . ."

No thought whatever can be recognised here. Isolated
words return ever again in various connections and trans-
formations : " most real of all — highest of all — first of all,"
" most real — reality," " and always, always — always again,"
" grave — httle graves of thoughts — little grave," " i, 2, 3,"
" Professor — Provisor." In " Gedankengriiftchen — schlan-
ken Griiftchen," and in " Provisor — Assessor — Professor "
clang-associations may be surmised ; and " i, 2, 3," — " a, b,
c " linguistic practice due to co-ordination might have been
the connecting link.

Many patients develop a veritable passion for writing,
cover innumerable sheets with very large fantastic calli-
graphy, the words crossing one another in all directions. An
example of this is given in the specimen of writing No. 2, with
its confused array of words, which in the most various kinds
of calligraphy run pell-mell hither and thither. It shows at
the same time in high degree the tendency to endless enumera-
tions, which sometimes appears in the writings of manic
patients, in so far as it is a case here of almost only

MANIC STATES

Specimen of Writing 2. — Manic Scribbling.

68 MANIC-DEPRESSIVE INSANITY

geographical names. It is remarkable that there are no re-
petitions as there are in catatonic documents which have
a similar appearance. The patients are also very fond of
composing poems, letters, petitions to highly placed person-
ages. In these the connection may be completely lost, as in
the following fragment of a rather long petition : —

" Rottach Waalberg (Rodel) Lorenz Tarok Katzenjammer Gautsch
Handelsrichter abgesagt 2 Grad (Celsius) 5000 Lire Kriegsentschadigung
zu bezahlen von Guadagnini fiir Ubernahme (Reich Dein III) schwarz
weiss 4/5 Bovril .\nnaberger Schliissel gelb 10 Pf. gehisst Chardonnerstag
Westnerday unvvohl Gallo Hohenzollern Kirche Vikar Bari Sprung Biringcr
Meisterspringer Zobel Max Arnulf 15. Febbrajo geboren bei Plinio Neapel
Appel Sanger I an Paralyse — Analyse — Stolze — Freytag Crispi bei Riva
Cavour bei Roosevelt . . ."

Only a few associations dependent partly on meaning,
partly on clang, can perhaps be found here : Rottach (beside
Tegernsee) — Waalberg (Wallberg) — Rodel," " Gautsch —
Handelsrichter (minister ?) — abgesiigt," " Chardonnerstag
— Westnerday (Wednesday ?)," " Bari — Biringer," " Sprung
— Meisterspringer, " " Neapel — Appel , " " Paralyse — An-
alyse," "Stolze — Freytag (Stolze — Schrey)," "Crispi —
Cavour — Roosevelt," " Plinio — Neapel," " Crispi — Riva —
Cavour ".

Delusional Mania.

The Delusions and Hallucinations, which in the
morbid states hitherto described are fugitive or merely in-
dicated, acquire in a series of cases an elaboration which calls
to mind paranoid attacks. His surroundings appear to the
patient to be changed ; he sees St Augustine, Joseph with the
shepherd's crook, the angel Gabriel, apostles, the Kaiser,
spirits, God, the Virgin Mary. Statues salute him by
nodding ; the moon falls down from the sky ; the trumpets
of the day of judgment are sounding. He hears the voice of
Jesus, speaks with God and the poor souls, is called by God
dear son. There are voices in his ears ; the creaking of the
floor, the sound of the bells take on the form of words. The
patient has telepathic connection with an aristocratic fiancee,
feels the electric current in the walls, feels himself
hypnotized ; transference of thought takes place.

The delusions, which forthwith emerge, move very fre-
quently on religious territory. The patient is a prophet,
John II, is enlightened by God, is no longer a sinner, is some-
thing supernatural ; he fights for Jesus, has to fulfil a divine
mission, is a-^piRit>- hides the world-soul in himself, intends to

MANIC STATES 6g

ascend to heaven, possesses secret power over mentally
afflicted people. He preaches in the name of the holy God,
will reveal great things to the world, gives commands accord-
ing to the divine will. Female patients are queen of heaven
and of earth, the immaculate conception, female clergyman,
mother of the heathen children ; they have a child by God,
are going to heaven to the bridegroom of their soul ; Christ
has restored their innocence to them. The devil is done away
with ; the patient has taken all the suffering of the world on
himself ; it is a wonderful world.

Other patients are descended from a royal house, are
princes, German and Austrian Emperors, Royal Highness,
destined to a higher hfe ; they possess millions, are to marry
a princess, a rich widow. They have already died a thousand
times, always come again, can practise magic, can help people
by prayer, can make themselves invisible. A patient had
" the feeling as if he would get money from somewhere " ;
another declared that he was the most distinguished private
detective ; a third called himself the " sanitary physician
of all the natural sciences and natural medical science " ; a
fourth said that he would be the most famous man in Europe ;
a fifth stated that he had found a female 193 cm. in height and
would get for her 40,000 marks. Female patients boast that
they are related to the royal house, are fourfold queens,
earthly somnambulists, have a beautiful voice, are going to
place the imperial crown on their husband. A female patient
declared that she was the Sleeping Beauty, had pricked her-
self with the spindle, and was now waiting for the Prince.
The patients often narrate all sorts of journeys and adven-
tures, secret experiences ; they have encountered men who
made assaults ; they were received in the capital with honour.
Many patients complain of persecutions, they have been ill-
used having been struck with the fist 130 to 150 times ; they
are fired at, whipped with rods.

Occasionally the delusions of the patients call to mind
those of the paralytic. They possess millions, diamond cups,
get a golden crown, have created mountains, built whole
cities. A patient wrote that he would offer his fiancee a life
such as no princess in the world had. " In Munich I shall
build for myself Castle Miramare, in Feldafing the Castle of
King Max formerly planned, make Munich the most beautiful
city in the world ; I have already designed three hundred
magnificent buildings, the most beautiful in the world. I
shall construct railways and gain millions by that."

70 MANIC-DEPRESSIVE INSANITY

These delusions are produced by the patients sometimes
in a theatrical manner, sometimes more in play. Sometimes
they are fleeting and changing ; but as a rule they are for a
considerable time adhered to and defended although with
very varying emphasis. The same ideas often appear again
in later attacks. The consciousness of the patients appears
as a rule to be slightly dulled. They perceive imperfectly,
have no complete understanding of what happens in their
surroundings, are not clear about time-relations, possibly also
make mistakes about individual people. Judgment about
their own condition is frequently led astray by hallucinations
and delusions. Their mood is cheerful, self-conscious,
visionary; a patient " wept tears of joy ". But at a time
the patients are also pretentious, high-flown and abusive
in all keys, or they break out suddenly in passionate
weeping.

Excitement is not usually very severe. In their conduct
the patients may appear approximately well ordered, but
they display a certain restlessness, meddle with everything,
sing, versify, preach, and work mischief. They want to buy
houses, distribute their money " among distressed children,"
throw everything into the collecting-box, make speeches from
the railway-train, give the benediction in pubUc. A patient
declared war on France ; others make attempts to cure their
fellow-patients, practise enchantment on them by solemn
movements of the arms.

Delirious Mania.

A Delirious State fills up the picture in a further group
of cases, whicli is not very large. This state is accompanied
by a dreamy and profound clouding of consciousness, and
extraordinary and confused hallucinations and delusions.
The attack usually begins very suddenly ; only sleeplessness,
restlessness or anxious moodiness may already be con-
spicuous one or two days, more rarely a few weeks, before-
hand. Consciousness rapidly becomes clouded ; the patients
become stupefied, confused, bewildered, and completely lose
orientation for time and place. Everything appears to them
changed ; they think that they are in heaven, in Herod's
palace, in the " Christchild Hospital." Mistakes are made
about the people in their surroundings ; their fellow-patients
are near relatives ; the physician is a Royal Highness, an
ecclesiastic, a black devil, A female patient, who in numer-.

MANIC STATES 71

ous similar attacks always fancied that she was surrounded by
historical celebrities, Louis XIV, Caesar, Elizabeth, called
that her " historical delusion ".

At the same time numerous hallucinations appear. Some-
thing is burning ; birds are flying about in the air ; angels
appear ; spirits throw snakes in the face of the patient ;
shadows come and go on the walls. The patient sees heaven
open, full of camels and elephants, the King, his guardian-
angel, the Holy Ghost ; the devil has assumed the form of the
Virgin Mary. The ringing of bells is heard, shooting, the
rushing of water, a confused noise ; Lucifer is speaking ; the
voice of God announces to him the day of judgment, re-
demption from all sins. The patient carries on dialogues
with absent people, receives revelations ; his thoughts are
borne from one voice to another. The coffee smells of dead
bodies, his hands as if rotten ; in the house there is a smell of
burning ; the food tastes of goat-flesh or of human flesh, the
water of sulphur. His head is very giddy, full of fever-heat.
The patients think that they are lifted and thrown into an
abyss ; they swim with the king in the ocean ; everything
is falling to pieces round them.

At the same time dreamy, incoherent delusions are de-
veloped. A terrible misfortune is coming suddenly ; the
patient feels the devil in his breast, has had a scuffle with him,
prides himself on his strength; he must die, go through terrible
struggles ; he is going to be poisoned, beheaded, is lost,
accursed, rotten, quite alone in the world. Everything is
annihilated ; God has shot himself ; all his relatives have
died. He has won the first prize in the lottery, is proclaimed
emperor, is the promised hero who is to redeem the world,
would like to go with his children to heaven. The millennium
has begun ; King Ludwig will rise from the dead ; the great
battle with the Antichrist is being fought.

Mood during this delirium is very changing, sometimes
anxiously despairing (" thoughts of death "), timid and
lachrymose, distracted, sometimes unrestrainedly merry,
erotic or ecstatic, sometimes irritable or unsympathetic and
indifferent. At the beginning the patients frequently display
the signs of senseless raving mania, dance about, perform
peculiar movements, shake their head, throw the bedclothes
pell-mell, are destructive, pass their motions under them,
smear everything, make impulsive attempts at suicide, take
off their clothes. A patient was found completely naked in
a public park. Another ran half-clothed into the corridor

72 MANIC-DEPRESSIVE INSANITY

and then into the street, in one hand a revolver in the other
a crucifix.

The patients do not trouble themselves at -all about their
surroundings ; they do not listen, they give no information,
obey no requests, are resistive, strike out. Their linguistic
utterances alternate between inarticulate sounds, praying,
abusing, entreating, stammering, disconnected talk, in which
clang-associations, senseless rhyming, diversion by external
impressions, persistence of individual phrases, are recognised.
Other patients only display a slight restlessness, whisper
flights of ideas to themselves, when addressed look up
astonished and without comprehension, obey simple requests,
give irrelevant answers, smile, weep, cling to people, suddenly
begin to sing a song or scream. A female patient called
out abruptly, " I am justice ; do not touch me ; I am
omniscient ; away from me ! " Waxy flexibihty, echolaUa,
or echopraxis can be demonstrated frequently.

As a rule the state is subject to manifold fluctuations.
The patients become at times quite quiet, but at first they are
not clear ; they remain incapable of thought and confused.
They then perhaps complain themselves that they cannot
collect their thoughts, are not in their right mind, that every-
thing is mixed, that they have so many thoughts in their
head. Often there can be observed repeated change between
excitement and stupor. The disappearance of morbid pheno-
mena takes place now and then fairly suddenly, much more
often gradually. Frequently there remain for some time
isolated delusions or remnants of them, and especially
fluctuations of mood, after the excitement and confusion
have already disappeared. The patients are at first still
distrustful, without insight, discontented, irritable ; perhaps
also they easily give way to flights of ideas, especially in
writing ; they are talkative or inaccessible ; they force their
way out. Little by httle the last morbid symptoms dis-
appear. Recollection of the delirious time is mostly rather
dim ; frequently there even exists almost complete amnesia.

The Course of manic attacks is very variable. The
commencement is almost always a period of anxious or
mournful mood, either marked depression lasting for months
or even years, or a prodromal stage of a few days or weeks.
Much more rarely and perhaps only when there is frequent
repetition, mania begins quite suddenly. A patient became
severely maniacal in the cemetery at his daughter's funeral,
without any change having been noticed in him before that,

MANIC STATES ^z

The height of the morbid phenomena is usually reached
fairly quickly, occasionally even within a few days. From
then onwards the state may just as quickly approach the
normal, though that occurs almost only in delirious forms,
much more rarely in simple mania, most rarely in hypo-
mania. As a rule, manic excitement is maintained for a con-
siderable time with approximately the same severity, though
always with manifold fluctuations. Very frequently there
are periods interpolated of mournful moodiness and even
passing stupor, a phenomenon which opens the way for the
understanding of the mixed forms to be discussed later.

The final quieting down usually appears very gradually
after somewhat long duration of the disease, while improve-
ments in the condition become always more distinctly
marked. The patients become clearer about their surround-
ings, more accessible, more attentive, but they still fall very
easily into the former flight of ideas. Even when the more
violent disorders have already gone into the background,
there usually still remains behind for sometime an increased
emotional irritability, heightened self-consciousness, as well
as a certain restlessness. Sudden outbursts of rage of sur-
prising violence may occur on trifling occasions, even after
apparently complete quiet has for long been present, especi-
ally in the later attacks with a protracted course. One often
sees also manic excitement flare up again if the patients get
into unfavourable circumstances or begin to drink.

The Duration of manic excitement is also subject to
great fluctuations. While occasionally attacks run their
course within a few weeks or even a few days, the great
majority extend over naAny months. Attacks of two or
three years' duration are very frequent ; isolated cases may
last considerably longer, for ten years and more. Especially
the forms with delusions and moderate excitement, increasing
only from time to time, appear readily to run a hngering
course ; also in hypomanic attacks one will frequently have
to reckon with a fairly long duration. Now and then, as
already formerly indicated, I have got the impression from
the course of the body-weight and the other phenomena, as
if it were a case of several attacks following close on one
another.

Very frequently after the disappearance of manic excite-
ment a more or less marked condition of weakness and
despondency appears, which is generally regarded as ex-
haustion after the severe illness ; it is obviously only a case,

^4 MANIC-DEPRESSIVE INSANITY

however, of the transition to depression peculiar to the dis-
ease. The patients are extremely susceptible to fatigue, in-
capable of any mental or bodily exertion, monosyllabic, dull,
irresolute ; they reproach themselves with their manic
actions, and are anxious about their future. These dis-
orders usually clear up gradually as the body-weight con-
tinues to increase.

CHAPTER V.
DEPRESSIVE STATES.

Melancholia Simplex.

The slightest depressive states are characterised by the
appearance of a simple psychic inhibition without hallucina-
tions and without marked delusions. Thinking is difficult to
the patient, a disorder, which he describes in the most varied
phrases. He cannot collect his thoughts or pull himself to-
gether ; his thoughts are as if paralysed, they are immobile.
His head feels heavy, quite stupid, as if a board were pushed
in front of it, everything is confused. He is no longer able to
perceive, or to follow the train of thought of a book or a con-
versation, he feels weary, enervated, inattentive, inwardly
empty ; he has no memory, he has no longer command of
knowledge formerly familiar to him, he must consider a long
time about simple things, he calculates wrongly, makes con-
tradictory statements, does not find words, cannot construct
sentences correctly. At the same time complaints are heard
that the patient must meditate so much, that fresh thoughts
are always coming to him, that he has too much in his head,
that he finds no rest, is confused.

The patients frequently describe that change of their in-
ward state, which is usually called " depersonalisation."
Their presentations lack sensuous colouring. The im-
pressions of the external world appear strange, as though
from a great distance, awake no response in them ; their own
body feels as if not belonging to them ; their features stare
quite changed from the mirror ; their voice sounds leaden.
Thinking and acting go on without the co-operation of the
patient ; he appears to himself to be an automatic machine.
Heilbronner has pointed out that Goethe has described
similar disorders in Werther, when he says : —

" O, when this glorious nature lies before me so rigid, like a little
varnished picture, and all the joy of it cannot pump a drop of bliss from vay
heart up to my brain," and " I stand as though in front of a cabinet of
curiosities, and I see little men and little horses moving about in front of
me, and I often ask myself whether it is not an optical delusion. I play
with them, or rather I am played like a marionette, and I sometimes take
hold of my neighbour by his wooden hand and start back shuddering."

76 MANIC-DEPRESSIVE INSANITY

Mood is sometimes dominated by a profound inward de-
jection and gloomy hopelessness, sometimes more by in-
definite anxiety and restlessness. The patient-'s heart is
heavy, nothing can permanently rouse his interest, nothing
gives him pleasure. He has no longer any humour or any
religious feeling, — he is unsatisfied with himself, has become
indifferent to his relatives and to whatever he formerly liked
best. Gloomy thoughts arise, his past and even his future
appear to him in a uniformly dim light. He feels that he is
worth nothing, neither physically nor mentally, he is no
longer of any use, appears to himself " like a murderer".
His life has been a blunder, he is not suited for his calling,
wants to take up a new occupation, should have arranged his
life differently, should have pulled himself together more.
" I have always given advice, and then things have gone
wrong," said a patient.

He feels solitary, indescribably unhappy, as " a creature
disinherited of fate " ; he is sceptical about God, and with a
certain dull submission, which shuts out every comfort and
every gleam of light, he drags himself with difficulty from one
day to another. Everything has become disagreeable to
him ; everything wearies him, company, music, travel, his
professional work. Everywhere he sees only the dark side
and difficulties ; the people round him are not so good and
unselfish as he had thought ; one disappointment and dis-
illusionment follows another. Life appears to him aimless,
he thinks that he is superfluous in the world, he cannot re-
strain himself any longer, the thought occurs to him to take
his life without his knowing why. He has a feeling as if some-
thing had cracked in him, he fears that he may become crazy,
insane, paralytic, the end is coming near. Others have the
impression as though something terrible had happened,
something is rising in their breast, everything trembles in
them, they have nothing good to expect, something is
happening.

Imperative Ideas of all kinds occasionally emerge in
these states, agoraphobia, mysophobia, the fear of having
been pricked by a splinter and having to die of blood-
poisoning, the fear of having vicious or " unclean " thoughts,
the idea of throwing people into water, the fear of having
stolen bread or money, of having removed landmarks, of
having committed all the crimes mentioned in the news-
papers. A patient was tormented by the idea of having
murdered people with his thoughts, and of having been guilty

DEPRESSIVE STATES 77

of the death of King Ludwig. A female patient, who in a
former attack had thought that she was an empress with a
court of dogs and cats, made convulsive efforts to get rid of
the word empress which always forced itself upon her, the
effort consisting in rubbing her teeth rhythmically with her
hand. Another was very greatly tormented by being com-
pelled to connect obscene sexual ideas with religious re-
presentations (crucifixes). A third patient wrote the follow-
ing in a note : —

" It is really so, that I have now become imclean with what I always
played with ; from negligence and clumsiness I often do not now go at the
right time to the closet and I pass something into my chemise, into my
bed, and into my clothes, and, as I always put on the clothes again, it so
happens that the petticoat is drawn on over the night-jacket, something
on there and on to my head, from the petticoat on to the bodice, on to the
hair and so on."

She was afraid also that something would fall out of her
nose into a book ; she often destroyed things supposed to be
» dirty ; she would not sit down on a chair or give her hand in
order not to soil anything. All these ideas she herself called
" on-goings," in order to make herself interesting. The fear
of knives, with the idea of being obliged to kill someone,
occurs occasionally also. A patient went to bed in order not
to do anything of that kind. One of my patients im-
pulsively stole all sorts of things which had no value for her-
self and of which she made no further use. She stated that
she could not help it, it was an impulse, just as if she had been
thirsty, she was uneasy if she did not yield to it. Gross by
means of " psychoanalysis " has arrived at the result here,
that the theft-impulse, being forced to do secretly what is for-
bidden, to take " something secretly into the hand," signifies
a transference of sexual desires unsatisfied by the impotent
lover, which has been further influenced by the question of a
priest at confession whether she herself had introduced the
organ in sexual intercourse. On other grounds also we may
perhaps regard these imperative fears and impulses as the
expression of a certain relationship between manic-depressive
insanity and the insanity of degeneration.

The Total Absence of Energy is very specially con-
spicuous. The patient lacks spirit and will-power, like a
wheel on a car, which simply runs but in itself has no move-
ment or driving power. He cannot rouse himself, cannot
come to any decision, cannot work any longer, does every-
thing the wrong way about, he has to force himself to every-
thing, does not know what to do. A patient declared that he

yB> MANIC-DEPRESSIVE INSANITY

did not know what he wanted, went from one thing to an-
other. The smallest bit of work costs him an unheard-of
effort ; even the most everyday arrangements, household
work, getting up in the morning, dressing, washing, are only
accomplished with the greatest difficulty and in the end
indeed are left undone. Work, visits, important letters,
business affairs are like a mountain in front of the patient and
are just left, because he does not find the power to overcome
the opposing inhibitions. If he takes a walk, he remains
standing at the house door or at the nearest comer, un-
decided as to what direction he shall take ; he is afraid of
every person whom he meets, of every conversation ; he
becomes shy and retiring, because he cannot any longer look
at any one or go among people.

Everything new appears uncomfortable and unbearable.
One of my patients insisted on leaving a post which he had
been very anxious to get, but he was alarmed at the removal
to a new residence, and importuned the authorities with con-
tradictory requests, as his new position immediately appeared
to him much worse than the former one. Finally the patient
gives up every activity, sits all day long doing nothing with
his hands in his lap, brooding to himself in utter dulness.
His sorrowful features show no play of emotion ; the scanty
linguistic utterances are laboured, low, monotonous and
monosyllabic, and even the addition of a simple greeting on a
postcard is not attainable or only after much urging.

Sometimes a veritable passion for lying in bed is de-
veloped ; the patients ever again promise to rise to-morrow,
but have always new excuses to remain in bed. Just because
of this severe voUtional disorder it relatively seldom comes to
more serious attempts at suicide, although the wish to die
very frequently occurs. It is only when with the disappear-
ance of inhibition energy returns while the depression still
continues, that the attempts at suicide become more frequent
and more dangerous. A patient with very slight moodiness
hanged himself a few days before his discharge on a free pass
when he already appeared quite cheerful.

Insight. — Sense and orientation are in spite of the great
difficulty in perception and thinking completely retained.
Generally a very vivid morbid feeling also exists, not in-
frequently even a certain morbid insight, in as far as the
patients express their regret for former improprieties, and
their fear lest they might again let themselves be carried away
by excitement. Others, however, think that they are not ill,

DEPRESSIVE STATES 79

only destitute of will-power, that they could indeed pull them-
selves together, only will not ; that they are simulating.
Frequently the return of moodiness is connected with ex-
ternal accidents, unpleasant experiences, changes in circum-
stances and such things. To the unprejudiced observer it is
clear that the psychic working of those influences has been
produced by the morbid clouding of disposition. A good
picture of the thinking and feeling of such patients is given in
the following letter : —

" Louisa, the whole truth ! It is all a squandering of money. I dare
not go home, I dare not stay here ; shut me up in a cell and give me only
bread and milk ; I am no longer ill ; they will not believe me ; I am loath-
some to myself and wholly weary of life, I may not further be a burden to
good people. I cannot write any more to my children, because I cannot
say to them, that they are no interest to me ; I am a horror and am hounded
by furies, the longer I am here, the wilder. You saw my lifeless expression,
Louisa ; you are a human being — have human compassion with me. Give
me only so much — to cover my nakedness ; everything else is torment to
me. Life itself is a frightful torment ; I must go to a house of correction ;
I must be forced to work. Here I cannot work, because anxiety worries
me about my condition. No medicine takes effect, because anxiety con-
sumes me. Here I had to pull myself together under such strict control,
but life is extinguished — how shall I manage among strangers, as I cannot
keep my things in order ? I go about with worn-out boots and cannot
provide myself with new ; money does not help me. My life is comfortless
and only bearable so long as I am complaining of my distress. Then I
hope for help. You will despise me instead of your former love. Louisa,
don't speak further of my misery."

The deep depression, the feeling of inward desolation and
indifference, the irresolution, the delusion of sin, the weariness
of life, lastly, the slight hope of help, appear distinctly here.

Stupor.

In the highest grades the psychic inhibition described
may go on to the development of marked stupor. The
patients are deeply apathetic, are no longer able to perceive
the impressions of the surroundings and to assimilate them,
do not understand questions, have no conception of their
position. A female patient who was made to leave hier bed
and go into the one beside it, said quite without understand-
ing, " That is too complicated for me." Occasionally, it can
be recognized that the inhibition of thought is slighter than
the volitional disorder. A patient was able to give the result
of complicated problems in arithmetic in the same time,
certainly considerably prolonged, as that of the simplest
addition.

Sometimes the occasional, detached utterances of the
patients contain indications of confused, delusional ideas.

MANIC-DEPRESSIVE INSANITY

that they are quite away from the world, have a crack
through the brain, are being sold ; down below there is an
uproar. A definite affect is at the same time mostly not re-
cognisable, yet in the astonished expression of the patients
their helplessness in regard to their own perceptions, and
further a certain anxious feeling of insecurity on attempting
anything can usually be seen.

Volitional utterances are extremely scanty. As a rule,
the patients lie mute in bed, give no answer of any sort, at
most withdraw themselves timidly from approaches, but
often do not defend themselves from pinpricks. Sometimes
they display catalepsy and lack of will-power, sometimes aim-
less resistance to external interference. They sit helpless

before their food ; per-
haps, however, they let
themselves be spoon-fed
without making any diffi-
culty. They hold fast
what is pressed into their
hand, turn it slowly about
without knowing how to
get rid of it. They are,
therefore, wholly unable
to care for their bodily
needs, and not infrequ-
ently they become dirty.
Now and then periods of
excitement may be inter-
polated. The patients get
out of bed, break out in

F,G. 1 7.-Dcprcs.ivo Stupor. conf USCd abuse, sing a folk-

song. Of the peculiarly strained, disturbed expression of
such patients. Figs. 17 and 18 give a good idea. After the
return of consciousness, which usually appears rather ab-
ruptly, memory is very much clouded and often quite
extinguished.

Melancholia Gravis.

The picture of simple depression corresponding perhaps
to the former " melancholia simplex," experiences very
varied elaboration through the development of hallucina-
tions and delusions, which frequently follows ; one might
here perhaps speak of a " melancholia gravis." The
patients see figures, spirits, the corpses of their relativ(

DEPRESSIVE STATES

something is falsely represented to them, " all sorts of
devil's work." Green rags fall from the walls; a coloured
spot on the wall is a snapping mouth which bites the
heads off children ; everything looks black. The patients
hear abusive language (" lazy pig," " wicked creature,"
" deceiver," " you are guilty, you are guilty "), voices, which
invite them to suicide ; they feel sand, sulphur vapour in
their mouth, electric currents in the walls. A patient, who

Depressive Stupor.

reproached himself with having had connection with a cow,
felt a cow's tail flicking his face.

Ideas of Sin usually play the largest part. The
patient has been from youth up the most wicked being, an
abomination, filled with malice, has led a horrible life, as far
as possible has let others do his work, has not put his full
strength into his calhng, has sworn falsely in taking the
military oath, has defrauded the sick fund. He has offended
everyone, has borne false witness, has overreached some one

82 MANIC-DEPRESSIVE INSANITY

in making a purchase, has sinned against the seventh com-
mandment. He cannot work any more, has no more feeUng,
no more tears ; he is so rough ; something is lacking in his
disposition. Frequently the self-accusations are connected
with harmless occurrences which have often happened long
before. The patient, when a child, communicated un-
worthily, did not obey his mother, told a lie before he was
twelve years old. He has not paid for his beer and on this
account will be imprisoned for ten years. A patient, fifty-
nine years of age, alleged that as a boy he had stolen " apples
and nuts," and " played with the genitals " of a cow. Con-
science is roused. " Certainly it' would have been better, if
it had been roused sooner," he said in answer to the objection
that up till then he had not been troubled about the supposed
sin. Others have once turned away a beggar unkindly, have
skimmed the cream from the milk. By renting a house, by
undertaking some building, by a thoughtless purchase, a
suicidal attempt, they have brought their family to misery ;
they should not have entered the institution ; then it would
all have come differently. Female patients have put too
much water into the milk of their dead children, have not
brought up their boys well, have neglected them in religion,
have procured the abortion of a cliild, have not had patience
in their confinements, have not kept their house properly ;
they do not put things in order, they are lazy. A female
patient, because of this, would not stay in bed. When it was
represented to another that it was a delusion, she replied,
" It is only conscience ; when I was at school it once came
like this." Obviously she was speaking of a former de-
pression.

The domain of religion is a peculiarly favourable soil for
self-accusation. The patient is a great sinner, cannot pray
any more, has forgotten the ten commandments, the creed,
the benediction, has lost eternal bhss, has committed the sin
against the Holy Ghost, has trafficked in divine things, has
not offered enough candles. He has apostatized from God, is
gripped firmly by Satan, must do penance. The spirit of
God has left him ; he feels that he dare not enter church any
more. He is going to Hell, has only two hours to live ; then
the devil will fetch him ; he must enter eternity with trans-
gression, and redeem poor souls.

The following extract from a letter of a married peasant
woman to her sister affords a glimpse into the spiritual state^
of siK^li Tvih'(>nf'4 : —

DEPRESSIVE STATES 83

" I wish to inform you that I have received the cake. Many thanks, but
I am not worthy. You sent it on the anniversary of my child's death, for
I am not worthy of my birthday ; I must weep myself to death ; I cannot
live and I cannot die, because I have failed so much, I shall bring my
husband and children to hell. Wc are all lost ; we won't see each other
any more ; I shall go to the convict prison and my two girls as well, if they
do not make away with themselves, because they were borne in my body.
If I had only remained single ! I shall bring all my children into damnation,
five children ! Not far enough cut in my throat, nothing but unworthy
confessions and communion ; I have fallen and it never in my life occurred
to me ; I am to blame that my husband died and many others. God
caused the fire in our village on my account ; I shall bring many people
into the institution. My good, honest John was so pious and has to take
his life ; he got nineteen marks on Low Sunday, and at the age of nineteen
his life came to an end. My two girls are there, no father, no mother, no
brother, and no one will take them because of their wicked mother. God
puts everything into my mind ; I can write to you a whole sheet full of
nothing but significance ; you have not seen it, what signs it has made. I
have heard that we need nothing more, we are lost."

Besides the marked ideas of sin there is to be noted the
delusional conviction, that her husband is dead and her son
must take his life, but especially the tendency to find " signs "
and " significance," which God sends (nineteen marks and
nineteen \/ears), the regret about the failure of an attempt
at suicide by cutting her throat, lastl}^ the remark that her
many sins have only now occurred to the patient.

His present activities also frequently give the patient the
opportunity for continual self-reproach. He notices that he
always commits fresh faults, talks at random so stupidly,
says things which he does not wish to say, offends everyone.
" What I do, is the wrong way about ; I must always retract
everything that I say," said a patient. He causes so much
trouble, is to blame that the others are so distressed, that
they are being taken away. " I have probably done all this,"
said a patient. He has brought in all his fellow-patients,
must care for them all, is responsible for them, complains
that he is really not able to feed the others, to do the work of
the head-waiter, to pay for them all. Everyone must go
hungry when he eats. A patient reported as follows about
his " offences against the doctors " : —

" The patient F. is very often vexed with himself when at the visit of
the physicians he does not greet relatively thank in a more friendly way,
he very often says : "I have the honour," which expression may be mis-
interpreted. The better and more usual responses to greetings, as " Good
morning," and expressions of gratitude, as " Many thanks for the kind visit,"
are often omitted. Then the patient must take offence at his position, that
is the position and attitude of his body. Very often he does not assume
the requisite demeanour towards such highly placed gentlemen. Just
made another offence ; I have omitted to rise from my seat when the chief
physician went past. At the washstand I omitted to show a boy h«w to
fill the basin. He of course might have asked me. But those who were

$4 MANIC-DEPRESSIVE INSANITY

near will certainly have blamed my conduct and not the boy's. Once I
omitted to hand the water to a patient, when he asked for it. It is true
that he did not apply directly to me ; he only called into the room ; others
were much nearer to him, but it would have been niv di!t<- ♦<■ !"'!'!l his
request at once."

Ideas of Persecution frequently exist in the closest
connection with the delusion of sin. Disgrace and scorn
await the patient everywhere ; he is dishonourable, cannot
let himself be seen anywhere any more. People look at him,
put their heads together, clear their throats, spit in front of
him. They disapprove of his presence, feel it as an insult,
cannot tolerate him any longer among them ; he is a thorn
in the side to all. Speeches in the club have reference to
him ; there is secret talking of stories about females ; he is a
bully, should hang himself, because he has no character.
Everywhere he notices signs. The writer of the letter quoted
above said that her twisted knot of hair signified that her
husband had hanged himself, the scarfs of her fellow-patients
that her children were drowned at home, A patient con-
cluded from the remark,- " Still waters run deep," that he
should drown himself. The patient therefore asks for an
explanation ; he did not know that such was his state.
'' What is being done with me ? " he asks anxiously. Things
are so put before him as if every step in his life had been
wrong. He defends himself, therefore, in despair against the
supposed accusations and declares his innocence. But I have
not done anything wrong, have stolen nothing, have not be-
trayed my country, such patients are heard to lament. They
are afraid that on the death of a relative they may be sus-
pected of poisoning (" Has poison been found ? "), that they
may be called to account for lese-majesty, or for a planned
assault.

Everywhere danger threatens the patient. The girls read
his letters ; strange people are in the house ; a suspicious
motor-car drives past. People mock him, are going to thrash
him, to chase him from his post in a shameful way, incarcerate
him, bring him to justice, expose him publicly, deport him,
take his orders from him, throw him into the fire, drown him.
The people are already standing outside ; the bill of indict-
ment is already written ; the scaffold is being put up ; he
must wander about naked and miserable, is quite forsaken, is
shut out of human society, is lost body and soul. His re-
latives also are being tortured, must suffer ; " I do hope they
are still at home." His family is imprisoned ; his wife has
drowned herself ; his parents are murdered ; his daughter

DEPRESSIVE STATES

wanders about in the snow without any clothes on. Every-
thing goes the wrong way ; the household is going to ruin ;
there is nothing more there but rags ; the clothes have been
changed at the laundry. Things have been pawned ; the
money is not sufficient, is false ; everything costs too much ;
everyone must starve. A woman said that her husband did
not like her any longer ; he wanted to kill her. Others re-
lease their husband, invite him to get a divorce.

His bodily state also appears to the patient to be fre-
quently in a very dangerous condition, which may be con-
nected with the dysaesthesic'e formerly described. He is in-
curably ill, half-dead, no longer a riglit human being, has
lung-disease, a tapeworm,
cancer in his throat, can-
not swallow, does not
retain his food, passes such
thin and such frequent
stools. Face and figure
have changed ; there is no
longer blood in his brain ;
he does not see any longer,
must become crazy, re-
main his whole lifetime in
the institution, die, has
already died. He has be-
come impotent by onanism,
has had a chancre from
birth, has incurable blood-
poisoning, infects every-
one, he must not be
touched. On this account
longer had

Fig. 19.

a woman no longer nad ^'^g- 19-— Depression,

the bread baked in the house. The people in his surround-
ings become ill and yellow through the nasty exhalation of
the patient, are already mentally disordered and weary of
life. Female patients feel themselves pregnant, have been
sexually ill used. Such a patient with a deeply troubled
expression is represented in Fig. 19.

Paranoid Melancholia.

When ideas of persecution and hallucinations of hearing
are frequently present and sense remains preserved, morbid
states may occasionally arise, which readily call to mind
alcoholic insanity, without alcohpl having any causal

86 MANIC-DEPRESSIVE INSANITY

significance (" paranoid melancholia "). The patients feel
themselves watched, are pursued by spies . and threatened
by masked murderers ; they catch sight of a dagger
in their neighbour's hand. On the street, in the re-
staurant from the neighbouring table, they heat isolated
remarks about themselves. In the next room a court of
justice is deliberating on their case ; intriguing is going on ;
experiments are made on them ; they are threatened with
secret words and with suspicious gestures. Delusional mis-
takes are made about people. One of my patients tried to
escape from his persecutors by taking a journey, but noticed
already in the station that they were accompanying him, and
he walked only in the middle of the street because the voices
threatened him with shooting as soon as he turned aside
either to the right or to the left.

In the course of the forms here described consciousness is
mostly clear, and sense and orientation are preserved. The
patients perceive correctly the conversations and occurrences
in their surroundings and then frequently misinterpret them
in a delusional way. They think perhaps that they are not
in the proper institution with proper physicians, but in the
convict prison, that fellow-patients are acquaintances or
members of their family ; they address the physician as if he
were the public prosecutor ; their letters are falsified ; what
is said in the surroundings has a hidden meaning. Their
train of thought is orderly and connected, although mostly
very monotonous ; the patients always move in the same
circle. of ideas ; on an attempt being made to divert them,
they return again immediately to the old track. All mental
activity is as a rule made difficult. The patients are absent-
minded, forgetful, are easily tired, progress slowly or not at
all, and at the same time are sometimes most painfully pre-
cise in details. Often a certain morbid feehng exists. T\w
head is darkened ; the patient speaks of his chimera- I
have something just like a mental disorder " ; " under-
standing, reason, and the five senses are lacking." There is
no question, however, of genuine morbid insight. Even if
his attention is called to earher similar attacks of which the
patient had formed a correct opinion, it makes no impression
on him. At that time everything was still quite different ;
now things are much worse ; now every possibility of being
saved is excluded.

Mood is gloomy, despondent, despairing. By per-
suasion or visits from relatives it may usually be somewhat

DEPRESSIVE STATES 87

influenced ; sometimes on such an occasion lively excitement
follows. On the other hand unpleasant news often makes
little impression. What happens in the surroundings also
usually affects the patients only slightly. " The noise does
not annoy me, but the unrest in myself," said a female
patient, when it was proposed that she should be trans-
ferred to another part of the building on account of the
disturbing surroundings. The patients very frequently com-
plain about the great inward excitement in spite of outwardly
quiet behaviour ; they may then give vent to it at times in
violent outbursts of anxiety. Not infrequently it takes the
form of an unquenchable home-sickness which drives the
patients perpetually to try to get away, deaf to all reason.
If one gives in to this, their state of mind deteriorates rapidly
at home, as a rule. Many patients in regard to their delusions
appear remarkably dull and indifferent, occasionally also
perhaps good-humoured and even cheerful.

In the Activities of the patients their volitional in-
hibition on the one hand makes itself felt, on the other the in-
fluence of their delusions and moods. They feel tired, in need
of rest, are no longer able to take care of themselves, neglect
themselves, spend no more money, take no nourishment,
wear very shabby clothes, refuse to sign the receipt for their
salary, as indeed they have not done any work. They shut
themselves up, go to bed. He there rigidly with a troubled ex-
pression in a constrained attitude, sometimes with closed
eyes, or sit timidly on the edge of the bed, because they do
not venture to lie down. Indications of automatic obedi-
ence are not rare. In other patients anxious restlessness is
predominant. They run off in a shirt, remain for days in the
forest, beg for forgiveness, entreat for mercy, kneel, pray,
pluck at their clothes, arrange their hair, rub their hands
restlessly, give utterance to inarticulate cries. Their utter-
ances are, as a rule, monosyllabic ; it is very difftcult to get
anything out of them. They do not give information on
their own initative, are immediately silent again, but, at the
same time, occasionally display in their writings a fluent and
skilful diction. Speech is mostly low, monotonous, hesitating
and even stuttering. CalHgraphy is often indistinct and
sprawling. There are also occasional omissions and doubling
of letters.

Suicide.— The extraordinarily strong tendency to suicide
is of the greatest practical significance. Sometimes it con-
tinually accompanies the whole course of the disease, without

88 MANIC-DEPRESSIVE INSANITY

coming to a serious attempt owing to the incapacity of the
patients to arrive at a decision. The patient buys a re-
volver, carries it about with him, brings it with him to the
institution. He would like to die, begs that he may be be-
headed, that he may be provided with poison ; he ties a scarf
round his neck, goes to the forest to search for a tree on which
to hang himself ; he scratches his wrist with his pocket-knife
or strikes his head against the comer of the table. One of
my female patients bought strychnine wheat and phosphorus
paste, but luckily only took the first, because the phosphorus
" smelt too filthy." Another stepped on to the window-sill
in the second storey in order to throw herself down, but re-
turned to the room, when a policeman, who by chance was
passing, threatened her with his finger.

Nevertheless the danger of suicide is in all circumstances
extremely serious, as the volitional inhibition may dis-
appear abruptly or be interrupted by violent emotion.
Sometimes the impulse to suicide emerges very suddenly
without the patients being able to explain the motives to
themselves. One of my female patients was occupied with
household work, when the impulse came to her quite abruptly
to hang herself ; she at once did so and was only saved with
difficulty. Subsequently she was not able to give any ex-
planation of her deed, and had only a dim recollection of the
whole occurrence.

Occasionally after indefinite prodromata the first distinct
morbid symptom is a suicidal attempt. Only too often the
patients know how to conceal their suicidal intentions behind
an apparently cheerful behaviour, and then carefully prepare
for the execution of their intention at a suitable moment.
The possibilities at their command are numerous. They may,
while deceiving the vigilance of the people round them, drown
themselves in the bath, hang themselves on the latch of the
door, or on any projecting comer in the water-closet, indeed
even strangle themselves in bed under the cover with a
handkerchief or strips of hnen. They may swallow needles,
nails, bits of broken glass, even spoons, drink up any
medicine, save up sleeping-powder and take it all at one time,
throw themselves downstairs, smash their skull with a heavy
object and so on. A female patient by sticking in pieces of
paper managed to prevent the upper part of a window, where
there was no grating, being properly shut, and then threw
herself down from the second storey in an unwatched
jnoment. Another who was shortly to have been discharged,

DEPRESSIVE STATES 89

was alone for a few minutes in the scullery ; she took a little
bottle of spirit and a match from the cupboard, which had
been left open through negligence, and having poured the
spirit over herself set herself on fire. Not at all infrequently
the idea occurs to the patients to do away with the family
also, because it would be better if none of them were alive.
They then try to strangle their wife, to cut their children's
throats, they go with them into the water, in order that they
may not also be so unhappy, that they may not get step-
parents.

Fantastic Melancholia.

A further, fairly comprehensive group of cases is
distinguished by a still greater development of delusions.
We may perhaps call it " fantastic melancholia." Abundant
hallucinations appear. The patients see evil spirits, death,
heads of animals, smoke in the house, black men on
the roofs, crowds of monsters, lions' cubs, a grey head
with sharp teeth, angels, saints, dead relatives, the Trinity
in the firmament, a head rising in the air. Especially
at night extraordinary things happen. A dead friend
sits on the pillow and tells the patient stories. The
patient thinks that he is on a voyage ; God stands beside
the bed and writes down everything ; the devil lies in
wait behind the bed ; Satan and the Virgin Mary come up
out of the floor. God speaks in words of thunder ; the devil
speaks in church ; something is moving in the wall. The
patient hears his tortured relatives screaming and lamenting ;
the birds whistle his name ; call out that he should be taken
up. " There's a black one, a sozi," it is said, " a vagabond,"
" Do away with him, do away with him," " Look, that's the
masturbator," " Now she's coming, now there'll be blood
again," " Now we've caught her nicely," " You have nothing
more," " You're going to hell." A woman is standing at the
door and is giving information to the persecutors ; there is a
voice in his stomach, " You must still wait a long time till you
are arrested ; you are going to purgatory when the bells ring."
The patient is electrified by the telephone, is illuminated at
night by Rontgen-rays, pulled along by his hair ; someone is
l3dng in his bed ; his food tastes of soapy water or excrement,
of corpses and mildew.

Besides those genuine hallucinations there are also multi-
farious delusional interpretations of real perceptions. The
patient hears murderers come ; some one is slinking about

90 MANIC-DEPRESSIVE INSANITY

the bed ; a man is lying under the bed with a loaded gun ;
an electro-magnet crackles. People with green hats or black
spectacles follow him on the street ; in the opposite house
someone is bowing conspicuously ; the motor-cars are making
a very peculiar noise ; in the next room knives are being
sharpened ; the conversations on the telephone refer to him.
Plays in the theatre, the serial story in the newspaper", are
occupied with him ; there is gross abuse written on a post-
card ; a female patient found her hat portrayed in a
fashion paper for mockery. There is a great deal of talk,
another said, and she imagined that it refererd to her. What
is said in the surroundings has a hidden meaning. Another
one asserted that the physicians spoke a " universal
language," in which they expressed all thoughts in a quite
different form not understood by her. The most extra-
ordinary conclusions are drawn from every perception ;
ravens flying signify that the daughter is being cut to pieces
in the cellar ; the son when he made his visit was wearinj^ i
black tie, so the youngest child must be dead. Everything
is "so fateful," comedy and illusion. " Everything simu-
lates, everything is talmi-gold," said a patient. The food is
flesh and blood of their own relatives, the light is a funeral-
light, the bed is an enchanted bed, the clattering cart out-
side is a hearse. It is quite another world, not the right
town, quite another century. The clocks strike wrong ; the
letters are as if from strangers ; the mortgages are exchanged ;
the savings-bank book is not valid. The trees in the forest,
the rocks, appear unnatural, as if they were artificial, as if
they had been built up specially for the patient, in fact, even
the sun, the moon, the weather, are not as they used to be.
One of my patients thought that the sun was artificial
electric illumination, and he complained about the weakness
of his eyes because he could not see tlie real sun (in the night).

The people, who visit the patient, are not the right people,
are only false show. The physicians are only " figures " ;
he thinks that he is surrounded " by elemental spirits " ; the
children appear changed. The nurse is a disguised empress ;
a fellow patient (female) thinks that the patient (also female)
is her husband ; the attendants have false names. The wife
is a witch, the child is a wild cat, a dog. A patient noticed
that her husband looked black, and on this account attacked
him with a bottle.

The numerous delusions are very extraordinary. The
patient has committed mortal sins, has caused a derailment.

DEPRESSIVE STATES 91

has killed many people, has brought on himself a primeval
sin, has murdered many souls ; he has forged documents, been
a legacy hunter, caused an epidemic. Because of sins of his
youth he is in detention ; he has committed bestiality ; he
is poisoning the whole world by his onanism. He has torn
down the firmament, drunk up the fountain of grace,
tormented the Trinity ; cities and countries are on his account
laid waste. The other patients are there by his fault, are be-
headed on his account ; every time that he eats or turns
round in bed, someone is executed ; the devil's mill is work-
ing over there ; they are being killed there, Female patients
have committed abortion, have been extravagant, have not
been good housewives, must be the devil's whore.

Because he is to blame for all misfortune, the patient is
going to hell. The devil slipped down the chimney to take
Jiiin asvay, has him by the nape of the neck, sits in his bosom
as a black beast with sharp claws, speaks in his heart ; he
himself is changed into the devil ; neither will his dead son
come into heaven. His baseness is revealed in his expression ;
everyone knows of his crime. No one likes him any longer ;
he is surrounded by spies, is watched by the police, is con-
tinually followed by suspicious people ; detectives wait for
him ; the judge is already there. He is dragged off to
Siberia, to the convict prison ; he is being electrocuted,
stabbed, shot, is having petroleum poured over him, is being
tied to a corpse, run over by the motor car, hacked to pieces,
cut up into a thousand bits, flayed, devoured by mice ;
naked in the wild forest he is being torn to pieces by wolves.
His fingers are being chopped off, his eyes dug out, his sexual
parts, his entrails cut off, his nails torn out ; women have
their womb drawn out. The last judgment is coming ; the
vengeance of God is at hand. To-day is the death-day, the
last meal before execution ; the bed is a scaffold ; the
patient wishes to confess once more. Over his family also
rnisfortuQe is poured out. His relatives are crucified by the
mob ; his daughter is in the convict prison ; his son-in-law
has hanged himself ; parents and brothers and sisters are
dead, his children are burned up. The husbands of female
patients have been murdered. The sister was cut to pieces,
sent away in a box ; the son's corpse was sold for dissection,

At home the patient is teased by everyone, regarded as
a fool, cheated ; people have no respect for him, spit in his
face ; the servants take everything from him with their
finger tips, because they think that he is syphilitic. All are

92 MANIC-DEPRESSIVE INSANITY

in alliance together and vent their anger on him ; many dogs
are the death" of the hare. The telephone conversations
were Hstened to ; the house was searched ; the things sent
to the laundry were lost ; false keys were found on the ring ;
at night the children were rendered insensible by gas. The
patient is surrounded by an international gang of robbers ;
his house is going to be blown up into the air. People knew
his career and his thoughts. At night he is sent to sleep,
taken away and made to carry out practical jokes, for which
he is later held responsible. A female patient aged sixty-five
complained of improper assaults, thought that she had been
brought to a house of ill-fame and was pregnant. Another
of the same age fanc'ed that she was exposed to the per-
secutions of old bachelors, who lay down beside her in bed.
A young girl asked if she would get a child. A woman forty-
eight years of age declared that she was pregnant and that
she had impregnated herself. An elderly man thought that
he was dragged about every night in brothels and there
infected with S3^philis. " I am here again," said a female
patient everytime she was visited, as she thought that she
was always being taken away each hour to a different place.

Hypochondriacal delusions usually reach a considerable
development ; they often completely resemble those of the
paralytic. In the patient everything is dead, rotten, burnt,
petrified, hollow ; there is a kind of putrefaction in him. He
has syphihs of the fourth stage ; his breath is poisonous ; he
has infected his children, the whole town. His head is
changing in shape, is as large as Palestine ; his hands and
feet are no longer as they were ; the bones have become
thicker, have shpped lower down ; all his limbs are out of
joint ; his body is no longer compact ; it stretches out and is
shrivelled up. In his skull there is filth ; his brain is melting ;
the devil has displaced it backwards by a discharge of blood.
His heart no longer cooks any blood, is a dead piece of flesh ;
his blood-vessels are dried up, filled with poison ; no cir-
culation goes on any longer ; the juices are gone. Every-
thing is closed ; in his throat a bone is sticking, a stone ;
stomach and bowel are no longer there. There is a worm in
his body, a liairy animal in his stomach ; his food falls down
between his intestines into his scrotum ; neither urine nor
faeces are passed ; his entrails are corroded. His testicles
are crushed, have disappeared ; his genitals are becoming
smaller. His mucous glands have risen up ; his life is
lacerated ; roUing about is going on at the navel. There is

DEPRESSIVE STATES 93

a hole in his nose ; there is pus in his jaw, in all his limbs, and
it passes away in great quantity with his motions and with
hawking ; his palate stinks. His skin is too narrow over the
-shoulders ; worms are lying under it and are creeping about.
A patient declared that for eleven years he had been a spirit,
and had only the internal organs left ; when some one died,
death passed through him and took away his entrails ; he
still had the scar. A female patient asserted that there was
iron in her and the bedstead attracted her. Another said
that she would get a child with a cat's head. Many patients
believe that they are bewitched inwardly, changed into a
wild animal, that they must bark, howl and rage. Others
cannot sit, cannot eat, cannot go a step, or give their hand.

The ideas of annihilation, already frequently indicated in
the foregoing pages, may experience a further, wholly non-
sensical elaboration. The patient has no longer a name, a
home, is not born, does not belong at all to the world any
more, is no longer a human being, is no longer here, is a spirit,
an abortion, a picture, a ghost, " just only a sort of shape."
He cannot live and he cannot die ; he must hover about so,
remain in the world eternally, is as old as the world, has been
already a hundred years here. If he is beaten with an axe
on his head, if his breast is cut open, if he is thrown into the
fire, he still cannot be killed. " I cannot be buried any
more," said a patient, " when I sit down on the weighing-
machine, it shows zero ! " The world has perished ; there
are no longer railways, towns, money, beds, doctors ; the
sea runs out. All human beings are dead, " poisoned with
antitoxic serium," burned, dead of starvation, because there
is nothing more to eat, because the patient has stuffed every-
thing down into his enormous stomach, and has drunk the
water-pipes empty. No one eats or sleeps any more ; the
patient is the only being of flesh and blood, is alone in the
world. A female patient declared that there was no blood
in her internal organs, therefore the electric light caught fire
from her, so that the whole human race and the firmament
were consumed. Another thought that a thunderstorm
would destroy the whole world.

Consciousness is in this form frequently somewhat
clouded. The patients perceive badly, do not understand
what goes on, are not able to form clear ideas. They com-
plain that they cannot lay hold of any proper thought, that
they are beastly " stupid," confused in their head, do not
find their way, also perhaps that they have so many thoughts

94 MANIC-DEPRESSIVE INSANITY

in their head, that everything goes pell-mell. Man) paiit-nls
say that they have been made confused by medicines and
much eating, that they have been hypnotized, that they con-
tinually talk nonsense, must profess sometimes one thing,
sometimes another, that they have become crazy. But at the
same time, when their delusions come into play, they are
incapable of recognising the grossest contradictions or of
correcting them ; they assert that they cannot take a bite
more while they are chewing with full cheeks. " This is my
last," said a patient every time the contradiction was pointed
out to her. Others beg to be sent out of the world by poison,
although they assert that they cannot die at all.

Yet the train of thought is usually in general reasonable.
They are frequently also able to give appropriate and con-
nected information about their personal circumstances and
more remote things, though certainly they are for the most
part little inclined to engage in such conversations, but
return immediately to their delusions again.

Mood is sometimes characterised by dull despondency,
sometimes by anxious tension or excitement ; at times the
patients are also repellent, irritated, angry, inclined to
violence. But not altogether infrequently we meet in the
patients slight self-irony ; they try to describe their sins and
torments in excessively obtrusive colours, use the language of
students, enter into a joke, allow themselves to smile ; erotic
moods also may be conspicuous. Especially in the last
periods of the attack a grumbling, insufferable, perverse
mood is developed, which only with complete recovery gradu-
ally disappears. A patient declared that she was envious of
the other children of God.

The Volitional Disorders are also not quite uniform.
The activity of the patients is frequently dominated by
volitional inhibition ; they are taciturn, even mute, cata-
leptic ; they lie with vacant or strained expression of
countenance in bed, often with closed eyes, do not ward ofif
pricks, do not do what they are bidden, are resistive when
taking nourishment, hide themselves under the cover, are
occasionally unclean. The inward tension is, perhaps, only
revealed by isolated whispered utterances (" Entreat for
me," " What's the matter ? "), convulsive grasping of the
rosary, imploring looks, excitement during the visits of re-
latives. Many patients feci themselves not free, but under
the influence of a higher power. A patient declared that
people had him in their power, he had lost his will

DEPRESSIVE STATES 95

completely, and was a broken man. A female patient was
obliged to kiss the floor and altar in church.

Anxious restlessness, however, seems to me to be more
frequent, occasionally alternating with slight stuporous
states. The patients do not remain in bed ; they wander
about, bewail and lament, often in rhythmical cadence,
" Sinful creature, wicked creature." They beg for forbear-
ance as they have not committed any fault ; people want to
kill them, to bury them alive, to throw them into the outer-
most darkness, into the river, into the fire, to poison them
and then have them dissected, to chase them out naked into
the forest, for choice when it is freezing hard. A patient
begged to be let down for execution. They refuse nourish-
ment, as they are not worthy of food, do not want to deprive
others of nourishment, cannot pay, observe poison or filth
in the dishes ; they would like to nourish themselves on
refuse and to sleep on bare boards. A patient ran about
bare-footed in order to be accustomed to the cold when
people chased him out into the snow.

At times more violent states of excitement may be inter-
polated. The patients scream, throw themselves on the
floor, force their way senselessly out, beat their heads, hide
away under the bed, make desperate attacks on the sur-
roundings. A female patient knelt down in a public ware-
house in front of religious pictures and tried to destroy
secular ones. Another made herself -conspicuous in the
tramway car by her loud self-accusations. A third in great
anxiety seized the full spittoon and emiptied it. A patient,
who was wholly disordered, suddenly proposed the health of
the Prince Regent. Serious attempts at suicide are in these
states extremely frequent. God commanded a female
patient to kill her relatives.

Delirious Melancholia.

From the form here described, which essentially corre-
sponds to the " melancholia with delusions" of Griesinger,
partly also to the " depressive insanity " of many investi-
gators, gradual transitions lead to a last, delirious group
of states of depression, which is characterized by profound
visionary clouding of conscience. Here also numerous, terrify-
ing hallucinations, changing variously, and confused delusions
arc developed. The appearance of people is changed ; faces
are distorted ; it is like a " wandering of souls." His wife
appears " queer " to the patient ; mistakes are made about

96 MANIC-DEPRESSIVE INSANITY

the nearest relatives ; a stranger is mistaken for the loved
one, a woman believed that her husband was mad. The
patient sees the Virgin Mary, the Christ-child, spirits, devils,
men, who wish to kill poor souls with the sword. Every
one is in mourning ; someone must have died. Clouds
sink down ; fire and flames rise upwards ; buildings with
wounded men are burning ; cannon are being brought up ;
the windows are turning round ; the sky is falling down.
The room stretches itself out into infinity, becomes heaven,
in which God sits on his throne, or it becomes the narrow
grave, in which the patient is suffocated, while outside
prayers for the dead are muttered. On a high mountain
sits a little manikin with an umbrella, who is always being
blown down again by the wind. The patient hears shooting,
the devil speaking, screams, terrifying voices ; twenty-seven
times it is said, " You are to die like a beast ! " Outside the
scaffold is being erected ; a numerous company is watching
him and scoffing at him ; the stove makes snappish remarks ;
the patient is ordered to hang himself in order to bury his
shame ; he feels burning about his body.

He is in a wrong house, in the law-courts, in a house of ill-
fame, in prison, in purgatory, on a rolling ship, attends the
solemn burial of a prince with funeral music and a large
retinue, flies about in the universe. The people round him
have a secret significance, are historical celebrities, divinities ;
the Empress, disguised as a maid-servant, cleans the boots.
The patient himself has become of another sex, is swollen Uke
a barrel, suffers from ulcers in his mouth and cancer ; he is of
high descent, guardian-angel, the redeemer of the world, a
war-horse. An action is brought against him ; he is to
blame for all misfortune, has committed treason, set the
house on fire, is damned, forsworn, and accursed ; it pene-
trates through his whole body. His lungs are to be torn out
of him ; wild beasts will devour him ; he is made' to wander
about naked on the street, is exhibited publicly as a Siamese
twin. A patient called from the window, " The devil is
taking me away ! " A female patient asked, " Am I allowed
to die in open death ? " The patient feels quite forsaken,
does not know what wrong he has committed, cries aloud,
" That is not true ! " The children have been shot by their
father ; the husband wants to marry the sister, the father-
in-law to kill the daughter ; the brother is threatening
murder. Everyone is lost ; all is ruined ; everything is
falUng to pieces ; everything is undermined. Seething and

DEPRESSIVE STATES 97

burning are going on ; there is revolution, murder, and war ;
in the house there is an infernal machine ; the justice of God
exists no longer. The whole world is burnt up and then
again becomes frozen ; the patient is the last man, the
wandering Jew, alone in desolation, immured in Siberia.

During these changing visionary experiences the patients
are outwardly for the most part strongly inhibited ; they are
scarcely capable of saying a word. They feel confused and
perplexed ; they cannot collect their thoughts, know ab-
solutely nothing any longer, give contradictory, incompre-
hensible, unconnected answers, weave in words which they
have heard into their detached, slow utterances which they
produce as though astonished. The following transcript dis-
tinctly shows the great confusion.

" One voice has choked the other — No, it wasn't so — It is something
peculiar — It was quite different — The house is athwart — Everyone has
poison — No, those ones cried out that — No, I've written it extra — Yes, now
I eat nothing more — If you had only done it otherwise, then it would have
been better — You would have written nothing at all — She alarmed everyone
— It isn't reall}^ a right sentry up there — Now it will never be better — ."

For the most part the patients lie in bed taking no interest
in anything. They betray no pronounced emotion ; they
are mute, inaccessible ; they pass their motions under them ;
they stare straight in front with vacant expression of counten-
ance like a mask and with wide open eyes. Automatic
obedience alternates with anxious resistance ; at times the
patients assume peculiar attitudes and make curious move-
ments. Temporarily they become restless, get out of bed,
wander slowly to and fro, force their way out, search round
about, want to pull other people out of bed, wring their hands,
cling to people, cry out, beg for pardon, protest their in-
nocence. Suicidal attempts also occur. A female patient
went with her children into the water and declared, " The
devil and lightning and electricity were in me." The taking of
food is frequently made ver}^ difficult owing to the resistance
of the patients.

The Course of states of depression is in general fairly
protracted, especially in more advanced age. Not infre-
quently their development is preceded by fluctuating,
nervous disorders and slight irritable or depressive moodiness
for years before the more marked morbid phenomena begin.
Sometimes they appear only as an increase of a slight morbid
state which had always existed.

The Duration of the attack is usually longer than in
mania ; but it may likewise fluctuate between a few days

98 MANIC-DEPRESSIVE INSANITY

and more than a decade. The remission of the morbid
phenomena invariably takes place with many fluctuations ;
not infrequently there is developed at the same time an
impatient, grumbhng, discontented behaviour, with restless-
ness and continual attempts to get away, which probably
should be connected with the admixture of slight manic dis-
orders.

When the depression disappears with remarkable rapidity,
one must be prepared for a manic attack. The improve-
ment of the phj^sical state is for the observer already very
conspicuous, while the patient feels himself not at all easier,
indeed worse, than formerly. That is perhaps related to the
fact that he is more distinctly aware of the disorder when the
natural emotional stresses have returned, than at the height
of the malady. Later an increased feeling of well-being may
take the place of depression ; this we must perhaps regard as
a manic indication even when it acquires no real morbid ex-
tent. A female patient wrote as follows in a letter of thanks
shortly after recovery from a rather long period of de-
pression : —

" I am now such a happy human being, as I never was before in my
whole life ; I simply feel that this illness, even though quite insane to
endure, had to come. Now at last, after a hard struggle, I may look for-
ward to a quiet future. My spirit is so fresh ; I absolutely don't need to
be trained, I cook with the greatest calmne.ss ... at the same time 1 keep
my ideals, which, God be thanked, life has left to me in spite of all that is
dreadful. And so my soul is in the greatest peace."

In other cases dejection, lassitude, lack of pleasure in
work, sensitiveness still persist for a long time after the more
conspicuous morbid phenomena have disappeared. Occa-
sionally also one sees hallucinations, which have arisen at
the height of the attack, diasppear very gradually although
the patients otherwise are perfectly unconstrained psychic-
ally and have acquired clear insight into the morbidity of the
disorder. A female patient, after recovery from a severe,
confused depression still for a number of weeks heard in de-
creasing strength "her brain chatter," and she made the
following notes about it : —

" I have nothing more, I do nothing more, I hke no one any longer, you
submissive thing, you ; I have no intention — must come here — they must
come here ; I know no one any longer — O God, O God, what shall I do,
when you have offended all here, in here, you impudent female, you . . ."

The content of these auditory hallucinations, which
betray a certain rhythm, is partly changing and disconnected,
but on the whole lets the trains of thought be recognised, by
which the patient was dominated in her depression.

CHAPTER VI.

MIXED STATES.!

If one follows more closely a considerable number of cases,
which belong to the different forms of manic-depressive in-
sanity, one soon observes that numerous transitions exist
between the fundamemtal forns of manic excitement and
depression, hitherto kept apart. Firstly, it has to be
pointed out that the individual attacks of the disease have by
no means permanently a uniform colouring. Manic patients
may transitorily appear not only sad and despairing, but
also quiet and inhibited ; depressive patients begin to smile,
to sing a song, to run about. Such sudden reversals lasting
for hours or for whole days are extremely frequent in
both directions. A patient perhaps goes to bed moody
and inhibited, suddenly wakes up with the feeling as if a
veil had been drawn away from his brain, passes the day
in manic delight in work, and next morning, exhausted and
with heavy head, he again finds in himself the whole misery
of his state. Or the hypomanic exultant patient quite un-
expectedly makes a serious attempt at suicide.

But then very often we meet temporarily with states
which do not exactly correspond either to manic excitement
or to depression, but represent a mixture of morbid symptoms
of both forms of manic-depressive insanity. This relation-
ship becomes most clear in the transition periods from one
state to another, which often extends over wrecks or months.
At the same time we do not see the phenomena of the one
state always disappearing at the same time in all the realms
of psychic life, and being replaced after a time of colourless
equilibrium by disorders of other kinds, which gradually
develop. Rather do some morbid symptoms of the earlier
period vanish more quickly, others more slowly, and at the
same time some or other phenomena of the state, which is
now developing are already emerging. If one examines more
precisely those transition periods, one is astonished at the

^ Weygandt, Uber die Mischzustande des manisch-depressiven Irre-
seins. Habilitationsschrift, 1899.

100 MANIC-DEPRESSIVE INSANITY

multiplicity of the states which appear ; some of them
scarcely seem compatible with the orthodox attacks. Never-
theless I believe that we can understand these states better,
if we assume that they proceed from a mixture of different
kinds of fundamental disorders of manic-depressive insanity.

If we begin with the cases which develop in the orthodox
manner, in which purely manic and purely depressive states
appear one after the other, we find at the height of the attack
combinations of definite symptoms which on the whole may
be regarded as psychological opposites. On the one hand we
meet with distractibility, flight of ideas, exalted ideas, cheer-
ful mood, volitional excitement ; on the other sluggishness of
attention and of thinking, ideas of sin and of persecution,
mournful or anxious mood, voHtional inhibition. In other
domains certainly, as that of perception, of mental work, of
judgment, there are no such contrasts ; they may , therefore,
be left out of consideration for the characterization of the
mixed states. In order to simplify, as far as possible, the
discussion based purely on principles, we will even restrict
ourselves to the consideration of the disorders of the train of
thought, of mood, and of volition, and at the same time for
the present make the assumption, that these three domains
of the psychic life form a unity and are similarly changed in
their totality by every disorder. In orthodox mania and
depression then all the three groups of psychic processes
would display deviations in the same direction, which roughly
might be contrasted as excitementand inhibition. It appears
meanwhile that besides such similar influences, dissimilar in-
fluences of the individual domains also occur owing to the
morbid process, with the mixed states as result. We ought
not to be surprised at this, as in nonnal psychic life also the
changes in the train of thought, in disposition and in will are
frequently divergent. Anxiety may paralyse thought and
action but also incite ; along with loud joj'ful excitement we
meet moods of quiet enjoyment, and along with rigid,
gloomy, painful depression wild outbursts of despair.

In order to explain first the frequent occurrence of mixed
states in the transition periods, it would only require the
assumption, that the transformation of the individual partial
disorders into their opposites does not begin simultaneously
but one after the other. According to this hypothesis one
disorder will already be transformed into its opposite, while
in other domains the former state still continues to exist. The
two following illustrations (Fig. 20) explain more clearly the

MIXED STATES

loi

possibilities arising here with hmitation to the three domains
mentioned above. They represent the transition from manic
excitement to depression and again to mania. The parts of
the curves above the horizontal line signify according to the
usual custom the partial disorders of mania, while the parts

<r**^^\" ••••

N \
S X

\
\

^-^ir::^:*^

•

/ ,

h 6

2 3

. -_-- Intellect

Fig. 20. — Comparison of the mixed states of manic-depressive insanity.

below the line indicate the transition to depression. The
disorders of thought are represented by broken lines, changes
in mood by dotted lines, volitional disorders by continuous
lines. In the first case illustrated, the disorder of thought is
transformed to its opposite earlier, the change of mood later

102 MANIC-DEPRESSIVE INSANITY

than the volitional disorder, while in the second case thought
and mood precede volition. In a similar way one may, of
course, demonstrate also various other possibilities, early
transformation of volitional disorder, simultaneous course of
two disorders before or after the third. As, however, here it
only concerns elucidation of the point of view, which has ted
to the doctrine of mixed states, it suffices to consider the
examples reproduced.

If we examine the first curve, the initial state would
correspond to that of manic excitement. At hne 4 the flight
of ideas has made way for inhibition of thought, while the
cheerful mood and pressure of activity still continue ; at Hne
6 voHtional inhibition has also developed. As now mood is
also transformed, we find at line 5 the picture of circular de-
pression at its height ; it dominates the situation for a con-
siderable time, although in somewhat changing combination.
At Hne 7 we have before us flight of ideas along with mournful
moodiness and voHtional inhibition, while a short time after-
wards at Hne 2 the volitional disorder has also changed and
only the depressive mood still persists. The further course
then again leads to the development of mania which lasts for
a considerable time.

In the second curve, which begins in a similar way to the
first, we have at Hne 2 the same state, which was developed
in the first curve before the fresh manic attack. But further
on at line 3 it comes to a combination of inhibition of thought
and depressive mood with excitement. After the complete
development of depression at Hne 5 there next follows again
2. state already known to us from the first curve, inhibition of
thought and volition with cheerful mood, but then at Hne 8
voHtional inhibition with flight of ideas and exalted mood.

If the transitions between the opposed states of manic-
depressive insanity ran their course similarly to the way here
described, we should in the first place infer that the transition
states have hitherto, in comparison with the two principal
forms, had relatively Httle attention paid to them, since they,
as a rule, are of very short duration. Moreover there may be
only a Hmited number of cases, in which the temporary
divergence of the changes from each other on the different
domains is at aU strongly marked. And further we must
picture to ourselves that the individual curves do not at all
run their course smoothly, but display manifold sudden
oscillations, so that the changing pictures become still more
blurred. But, on the other hand, the conception described

MIXED STATES 103

here would make it appear comprehensible that even in the
pure pictures of mania and of depression the relation of the
partial disorders to one another may change within wide
limits. Volitional inhibition may be extremely severe, while
moodiness is comparatively little marked, and vice versa ;
manic patients may have great flights of ideas but, at the
same time, not be much excited ; they may display ex-
tremely exalted mood with slight distractibihty and so on.
Even in the course of the same attack we not infrequently
meet with a quantitative change in states of the same kind.
We must now, however, put the question, whether then
clinical experience actually shows us morbid states which
correspond to the hypotheses laid down here. Although our
resources for the analysis of the individual phenomena are
still very incomplete and a really systematic investigation of
the mixed states and the conditions of their development has
till now scarcely been attempted, I stiU think that I may
reply to that question in the affirmative. As soon as one's
eye is trained to these observations, one very soon recognises
that in truth the orthodox descripton of mania and of cir-
cular depression is only to some extent appropriate for certain
of the principal forms. Round these are grouped a multi-
plicity of states of various kinds, which, meanwhile, as far as
we are able to judge, appear to be composed of quite the same
fundamental disorders. Those which are immediately derived
from the above considerations, we shall here discuss shortly.

1. Mania. — We begin with the picture of mania with
flight of ideas, exalted mood, and pressure of activity.

2. Depressive or Anxious Mania. — If in the picture
depression takes the place of cheerful mood, a morbid state
arises, which is composed of flight of ideas, excitement, and
anxiety. The patients are distractible, absent-minded, enter
into whatever goes on round them, take themselves up with
everything, catch up words and continue spinning out the
ideas stirred up by these ; they do not acquire a clear picture
of their position, because they are incapable of systematic
observation, and their attention is claimed by every new im-
pression. They complain that they must think so much,
their thoughts come of themselves, they have a great need of
communicating their thoughts, but easily lose the thread,
they can be brought out of the connection by every inter-
polated question, suddenly break off and pass to quite other
trains of thought. Many patients display a veritable passion
for writing, and scrawl over sheets and sheets of paper with

104 MANIC-DEPRESSIVE INSANITY

disorderly effusions. At the same time ideas of sin and per-
secution are usually present, frequently also hypochondriacal
delusions, as we have formerly described them.

Mood is anxiously despairing ; it gives itself vent in great
restlessness, which partly assumes the form of movements of
expression and practical activity, but partly also passes over
into a wholly senseless pressure of activity. The patients run
about, hide away, force their way out, make movements of
defence or attack ; they lament, scream, screech, wring or fold
their hands, beat them together above their head, tear out
their hair, cross themselves, slide about kneeling on the floor.
With these are associated rhythmical, rubbing, flourishing,
snatching, turning, twitching movements, snapping with the
jaw, blowing, barking, growhng. If one will, one might here
speak of a " depressive " or " anxious " mania.

3. Excited Depression. — If in the state described the
flight of ideas is replaced by inhibition of thought, there arises
the picture of excited depression. It is here a case of patients
who display, on the one hand, extraordinary poverty of
thought but, on the other hand, great restlessness. They
are communicative, need the doctor, have a great store of
words, but are extraordinarily monotonous in their utter-
ances. To questions they give short answers to the point,
and then immediately return to their complaints again, which
are brought forth in endless repetition, mostly in the same
phrases. About their position in general they are clear ;
they perceive fairly well, understand what goes on, apart
from delusional interpretation. Nevertheless they trouble
themselves little about their surroundings, they are only
occupied with themselves.

Mood is anxious, despondent, lachrymose, irritable,
occasionally mixed with a certain self-irony. Sometimes one
hears from the patients witty or snappish remarks. Delu-
sions are frequently present, but they are usually scantier and
less extraordinarily spun out than in the form just described.
The excitement of the patients also is usually not so stormy
or protean. They run hither and thither, up and down,
wring their hands, plu< k .it things, speak loud out straight in
front of them, give utterance to rhythmic cries and torment
themselves as well as their surroundings often to the utter-
most by continuous, monotonous lamenting.

4, Mania with Poverty of Thought. — Again another
picture is developed, when now depression is transformed to
cheerfulness. We have then before us a manic state without

MIXED STATES 105

flight of ideas, an unproductive mania with poverty of
thought. This state is very frequent. The patients perceive
slowly and inaccurately, often only understand questions on
repeated, impressive repetition, pay no attention at all,
frequently give perverse, evasive answers, cannot im-
mediately call things to mind. Nothing at all occurs to
them ; their conversation is, therefore, very monotonous
and empty ; the same students' phrase, jocular or vigorous,
is produced ever again with sniggering laughter. The
patients, therefore, not infrequently make a definite im-
pression of weakmindedness, while later they may even prove
themselves to be specially gifted. The state is subject to
great fluctuation, so that the patients temporarily are quick
and clever at repartee, while at other times they are in-
capable of saying an^^thing at all.

Mood is cheerful, pleased, unrestrained ; the patients
laugh with and without occasion, are dehghted with every
trifle. Now and then they are somewhat irritated, repellent,
or deliberately coarse, immediately afterwards breaking out
into a merry laugh. Excitement is often limited to making
faces, occasional dancing about, wanton throwing things
here and there, changes in dress and coiffure, without any
display of busyness, such as is otherwise peculiar to mania.
The patients are, however, very excitable, and quickly
becomes noisy and clamorous, as soon as they find them-
selves in unrestful surroundings. While they in general do
not speak either with special haste or very much, and often
for a considerable time behave quite quietly, it may happen
that in the course of a conversation an increasing flow of talk
develops. Many of these patients conduct themselves in
general so quietly and methodically, that to superficial ob-
servation excitement does not appear at all. Others sit
about in idleness, and when addressed burst out laughing,
but give utterance to nothing except a pert remark. In-
variably one also notices that they are incapable of any
regular occupation, but rather display a tendency to all sorts
of mischievous tricks and silly jokes ; they make collections,
steal and tear up things, make knots, stop up key-holes, stick
scraps of paper on to the wall, are wantonly destructive. At
times it comes also to very abrupt, short-lived, impulsive
outbursts of great violence, vSuch a patient without cause
suddenly jumped out of the bath, knocked down the attend-
ant with a chair, smashed several window-panes, and slipped
out completely naked into the snow-covered garden, where

io6 MANIC-DEPRESSIVE INSANITY

he quietly let himself be caught, as if nothing at all had
happened ; he was also incapable of giving any motive what-
soever for his action.

5. Orthodox Depression with inhibition of thought,
mournful moodiness and irresoluteness.

6. Manic Stupor. — If here mournful mood is replaced
by cheerful mood, that form arises which first instigated me
to investigate the mixed states, and which we usually call
" manic stupor." The patients are usually quite inaccessible,
do not trouble themselves about their surroundings, give no
answer, at most speak in a low voice straight in front, smile
without recognizable cause, lie perfectly quiet in bed or tidy
about at their clothes and bed-clothes, decorate themselves
in an extraordinary way, and all this without any sign of out-
ward restlessness or emotional excitement. Not infrequently
catalepsy can be demonstrated.

Occasionally isolated delusions of changing content find
utterance. The patients feel cold in their brain, have an iron
tongue, are devoured by polar bears, are the exchanged child
of a prince, Eleonora von Halberstadt. But for the most
part they prove themselves fairly sensible and oriented.
Quite unexpectedly, however, they become lively, give utter-
ance to loud and violent abuse, make a pert, telling remark
amidst unrestrained laughter, jump out of bed, throw their
food about the room, suddenly take oi^ their clothes, run in
double quick time through several rooms, tear up a garment
or ill-use a fellow-patient without external cause, and im-
mediately sink back again into their former inaccessibility.

At other times one finds them perhaps even quiet, sensible
and intelligent, for the most part certainly only quite
temporarily. Many patients wander with measured step
about the ward, scarcely speak at all, but occasionally make
a joke, call the physician by his first name, force their way
erotically to him, smile. One night such a patient stole the
keys from the nurse who was asleep, and escaped into the
room of one of the physicians ; she enjoyed the successful
trick very much but never spoke a word.

The patients often have a quite accurate recollection of
the time that has elapsed, but are totally unable to explain
their singular behaviour. " I wanted to have no will," one of
these patients said to me. He had refused food in order to be
Hghter and so attain to health, but felt himself caused by
hunger to sip a large quantity of milk through his nose and to
smell a roll passionately. In carrying out these singular

MIXED STATES

107

arrangements he smiled himself, but did not speak a word and
did not let himself be dissuaded from it.

A certain idea of this state is perhaps given by Fig. 21,
In the rigid expression of countenance of the patient who
always remains standing on the same spot, the constraint can
be distinctly recognised, which for many months has domin-
ated her and made her dumb. But, at the same time, there
appeared in the almost invincible tendency to destructiveness
and filthy habits, the fundamental manic feature of the dis-
order, which in the adornment of torn-off leaves and twigs is
recognisable also in the picture. In other patients the
expression is more cheerful, sportive, erotic. This state is
often interpolated, only
temporarily, in a pronoun-
ced manic attack. Still
more frequently it forms
the transition between de-
pressive stupor and the
mania which goes along
with it, as was assumed in
our second curve. One
may then follow step by
step the various intermed-
iate stages, the yielding of
the mournful moodiness,
the appearance of the first
smile, the movements be-
coming freer, the develop-
ment of a certain restless-
ness with low whispering,
and lastly, the disappear-
ance of inhibition in the

l'"iG. 21. — Manic htupor.

domain of speech also, with the bursting forth of pressure
of speech and flight of ideas.

7. Depression with Flight of Ideas — In the usual
picture of depression inhibition of thought may be replaced
by flight of ideas. These patients are incited by their de-
lusions to vivid associations of ideas, they read much, show
interest in, and understanding of what goes on in their
surroundings, perhaps even sheer curiosity, although they
are almost mute, and are rigid in their whole conduct and are
of cast-down and hopeless mood. We then hear from them
as soon as they again begin to speak about their state, that
they cannot hold fast their thoughts at all, that constantly

io8 MANIC-DEPRESSIVE INSANITY

things come crowding into their head, about which they had
never thought. Regard being had to the other experiences
in the mixture of morbid symptoms, the assumption is easy,
that in such cases we have to do with the appearance of a
flight of ideas which only on account of the inhibition of ex-
ternal movements of speech is not recognizable. A female
patient connected plays on words with what she heard.
When a rose was given to her, she said that meant that she
was guilty (Rose-reo sei). In spite of great moodiness she
used pecuUar slang expressions ; she spoke of the super-
intendent of the institution as the " chief bonze," " the Lord
of hosts."

Occasionally the patients, who cannot give utterance to
anything at all in speech, are capable of writing, and then
compose to our astonishment comprehensive documents,
often desultory, full of ideas of sin and delusional fears. A
sad, moody, taciturn patient with distinct volitional in-
hibition, when he felt himself offended by a fellow-patient,
whom, he thought, he had himself injured before, wrote as
follows : —

" Now one might regard this conduct as retaliation, as equivalent, as a
sweet revenge, well yes, but the Christian forgives, does not bear a grudge,
forgets the wrong that has been done to him, does not abuse in return, when
he is abused. If any one strikes you on the right cheek, turn to him the
other also, says the Lord and Saviour and diverges here from the precepts
of the Old Testament, where it says, " An eye for an eye, and a tooth for
a tooth." Do not reward evil with evil or with abuse. Forgive one another
as Christ has forgiven you."

The heaping up of synonymous phrases, the jumping off
to side thoughts, show here distinctly the flight of ideas, which
certainly was only recognizable in his writings. The patient
felt it himself, while he wrote : —

" I am again becoming prolix ; I therefore consider it better to hasten
to a conclusion, for long-winded explanations weary the reader, and are at
the least felt as want of consideration ..." "I also in writing repeat words
which mean the same, as lack of energy and lack of will ; both expressions
mean the same. ..."

At the same time the patient spoke " of his over-great
anxiety, of his lack of energy, in consequence of which,
activity, the coming out of oneself, tlie firm will, the strong
will-power are absent."

To this kind those cases may perhaps also be reckoned,
the sad and moody patients, in whom the tendency to
imaginative composition appears. One might perhaps call
this picture " depression with flight of ideas." Not

MIXED STATES 109

infrequently, as our first curve also indicates, manic excite-
ment is developed with disappearance of volitional inhibition
and transformation of mood.

8. Inhibited Mania. — Finally, I have also repeatedly
come across states which would correspond with the last
combination assumed by us, flight of ideas with cheerful
mood and psychomotor inhibition. The patients of this kind
are of more exultant mood, occasionally somewhat irritable,
distractible, inchned to jokes ; when addressed they easily
fall into chattering talk with flight of ideas and numerous
clang associations, but remain in outward behaviour con-
spicuously quiet. He still in bed, only now and then throw out
a remark or laugh to themselves. It appears, however, as
if a great inward tension, as a rule, existed, as the patients
may suddenly become very violent. Formerly I classified
this " inhibited mania " with manic stupor ; I think, how-
ever, that it may be separated from that on the ground of the
flight of ideas which here appears distinctly.

Perhaps we may, as Stransky indicates, regard as the
slightest form of these states the " shamefaced mania " which
he mentions. In this the patients behave quite quietly in
the presence of the physician, are perhaps even taciturn and
motionless, although cheerful, while among their equals they
may be fairly lively and high-spirited. It appears that here
the inhibitions of embarrassment are by themselves sufficient
to suppress the manic pressure of activity.

The doctrine of the mixed states is still too incomplete for
a more thorough characterization of the individual forms to
be advisable at present. Nevertheless attention may be
directed here to some points of view which may be of signi-
ficance for the further development of our knowledge in this
domain, indeed, to a certain extent have already been so.

Partial Inhibition and Exataltion. — The idea of
" partial inhibition," as it has been introduced into the
doctrine of the mixed states by Dreyfus, Pfersdorff and
Goldstein, finds without doubt its justification in the fact,
that the classification of the psychic life, which forms the
foundation of our arguments, naturally only reflects the very
roughest outlines. First, it must be remarked that at the
same time a whole series of psychic processes, which certainly
might underlie independent disorders, have received no con-
sideration at all, as the behaviour of attention, perception,
impression, psychic work, the formation of judgments and
inferences and so on. It would be conceivable that through

no MANIC-DEPRESSIVE INSANITY

more accurate consideration of the varying changes which
appear in individual cases in these and many other domains,
the multiphcity of forms would be still considerably en-
riched.

Here I will only bring forward a single experience, the
frequent contradiction between the content of the delusions
and the colouring of mood. A patient told me with laughing
that his nerves were dried up and his blood circulated only as
far as his neck. A depressed female patient spoke of the in-
ward voice, which she heard, as of a " grace " ; others state
with an air of secrecy that they are considered to be the
Virgin Mary, that they are to be confined with Christ, that it
is believed of them that they could work miracles, make gold,
cure all diseases. Many patients speak cheerfully of their
approaching death. In this domain also there are mixtures
which do not correspond to ordinary behaviour. Moreover,
there are manic patients who, as has already been partially
indicated above, are not distractible, at least not by external
impressions, and depressive patients whose attention may be
excited with extraordinary ease.

Possibly more important than these phenomena, which
are perhaps quite unessential, is the fact, that the three great
domains of the psychic life, which we have laid as the founda-
tion of our discussion are, in reahty, nothing less than unities.
Inhibition and excitement may attack partial domains
separately, and so exist beside each other in the same
territory. The pairs of opposites, which we have taken, are,
therefore, only vahd for the general grouping of the states,
but in detail are frequently not sufficient. So in the domain
of thought, there may apparently be a separation between
conceptual thought, the emergence of sensuous memory
pictures, and the occurrence of linguistic presentations. As
already mentioned, there are patients who, without any
difficulty worth speaking about, can think conceptually, but
who feel most painfully the colourlessness of the presentations
which emerge.

But then we occasionally observe beside each other in-
hibition of thought and flight of ideas. ^ The patients display
great psychic dulness, but at the same time desultoriness of the
train of thought and a tendency to Unguistic clang associa-
tions. From this it appears that inhibition of thought and
flight of ideas are by no means the kind of opposites which
they might appear according to ordinary clinical epxerience,
^ Schroder, Zeitschr. f.d. ges. Neurol, u. Psych., II, 57.

MIXED STATES iii

In fact we may likewise artificially produce by bodily exertion
or by the use of alcohol states in which difficulty in thinking
is combined with flight of ideas. Perhaps we may assume
that there are various forms of inhibition of thought, accord-
ing to whether conceptional, sensuous and linguistic thought
are simultaneously or only partly disordered. When the
domain of linguistic presentations is not affected by the in-
hibition or even is itself in a state of excitement, flight of
ideas might exist along with difficulty in thought. I should
like merely to indicate that probably we should also differ-
entiate between inhibition of thought and monotony of
thought ; likewise increased activity of imagination, as we
observe it in the slighter forms of manic excitement, must be
separated from flight of ideas.

In the other domains of psychic life things are very
similar. The cheerful and the mournful or anxious mood
are not simple opposites which are mutually exclusive, but
they may mix with each other in the most different ways.
Not at all infrequently we observe in our patients, as already
mentioned, a kind of grim humour, which is compounded of
despair and amused self -derision. The angry irritation also,
which we meet so often in the most different states, is, as
Specht ' has rightly emphasized, to be regarded as a mixture
of heightened self-consciousness with unpleasant moods. By
the continued predominance of such a mixture of moods that
state is characterized before everything, which is usually
called " acute delirious mania," raving mania. This includes
cases of pronounced manic excitement, in which the patients
on the slightest occasion fall into outbursts of furious anger,
overwhelm their surroundings with abuse, and become
senselessly violent. To this group those manic patients
probably belong, who are constantly peevish, repellent, in-
accessible, who give pert answers, make scornful remarks,
torment and ill-use their fellow-patients. If with that is
compared the imperturbable cheerfulness and amiability of
other patients who are just as excited, it becomes clear that
peculiar mixtures of moods must here be present.

If in these cases the excitement is moderated, the
grumbling forms of mania perhaps arise, to the slightest
phases of which Hecker has specially drawn attention. The
patients, indeed, display exalted self-consciousness, are pre-
tentious and high-flown, but by no means of cheerful mood ;
they rather appear dissatisfied, insufferable, perhaps even a

1 Specht, Zentralblatt f. Nervenheilk., 1907, 529 ; 1908, 449.

112 MANIC-DEPRESSIVE INSANITY

little anxious. They have something to find fault with in
everything, feel themselves on every occasion badly treated,
get wretched food, cannot hold out in the dreadful surround-
ings, cannot sleep in the miserable beds, cannot have social
intercourse with the other patients. Along with perfect
sense they have a great tendency and capacity to offend and
to hurt others, to stir them up, to incite them, everywhere
to find out the unpleasant and place it in the foreground.
Every day they bring forward fresh complaints, act as
guardian to the people round them, are irritated, when, in
their opinion, sufficient attention is not paid to them. The
manic foundation is indicated in talkativeness, sUght flight
of ideas, great unsteadiness and restlessness, which drives
the patients to wander about a great deal, to begin all possible
cures without carrying through a single one, to smoke and to
drink excessively.

Partial Mixtures — If in the description of the clinical
states we place. "the colouring of mood in the foreground, there
is no doubt at all, that the firmness also with which an
emotion persists, and the strength of the emotional stress
which the occurrences of life call forth, must be of essential
significance for the formation of the state. In general much
more pronounced fluctuations of mood are observed in manic
patients, but here also displacements occur, manias with im-
perturbable unchanging cheerfulness and depressions with
frequent fluctuations of mood. The pecuUar weakening of
the emotional response, which is felt so painfully by many
sad and moody patients, apparently does not occur equally
in all forms of depression ; it may for example be absent in
states of great anxiety. On the other hand we often enough
miss the great vivacity of emotional stress, which distin-
guishes many slightly manic patients, in other manic states.

The colouring of delusions in general stands in close con-
nection with mood, although here also, as already mentioned,
contradictions appear to occur, which meanwhile might
possibly be connected with the existence of mixtures of
moods. But further a remarkable mixture of depressive and
exalted ideas is often observed. The immeasurableness of
the persecutions, to which the patients are exposed, might
well be interpreted in this sense. A patient asserted that he
had got cantharidin by the hundredweight. Another de-
clared that his relatives had to live among robbers for
trillions of years. A third, who believed that all his inside
was destroyed and lacerated, said that the doctor might be

MIXED STATES 113

proud to be allowed to treat him, a case of the kind had not
occurred for six hundred years. Others are fetched away by
" millions of devils," dragged to an " extra scaffold," per-
secuted by Kaiser and King, taken to America by the Kaiser
in order to be shot there. Certain theatrical features in the
depressive ideas probably also belong here. A female patient
in despair described her approaching execution, and added
with a satisfied sidelong glance at her neighbour, " and
Gretchen must crack the whip." Another wished to die a
" romantic death," wished to confess her sins openly. A
third desired to be allowed as a martyr to embrace lions and
leopards in their cage.

Perhaps the fact of limited inhibitions and excitements is
most distinctly seen in the domain of volitional processes.
The experiments with the writing-balance have already
shown that in the simple action of writing the force and the
rapidity of the movement may be changed in different
directions. In still much higher degree must that be valid
for the intricate processes of which an independent volitional
action is composed. The decision, the impulse, its force, the
rapidity of its transformation into actual activity may in-
dependently of each other be subject to disorders, and these
disorders may again extend to different distances over the
individual domains of activity. In fact we know some ex-
periences, which go to prove that the expressions " volitional
inhibition " and " volitional excitement " represent large
general conceptions which must often be analysed. Rapidity
or sluggishness of decision may exist without the external
volitional action being recognizably changed. Dreyfus has
directed attention to the fact, that a feeling of inhibition, a
" subjective " inhibition may be present even without re-
cognizable sluggishness of the action ; certainly it will be a
case here of finer disorders which do not yet lead to definite
results. Juliusburger has described cases with only sub-
jective inhibition and a vivid feeling of depersonalisation as
" pseudo-melancholia."

We observe further great inward restlessness, therefore
volitional excitement, while the making of decisions and the
carrying out of voluntary actions is difficult, indeed, the
restlessness may even discharge itself in lively movements of
expression without the volitional inhibition disappearing.
From this we recognize that the impulsive discharges of states
of inward tension may be influenced by the morbid process in
another way than purposeful volition and activity.

114 MANIC-DEPRESSIVE INSANITY

Movements of linguistic expression also take up a peculiar
position. Excitement and inhibition in the domain of speech
and writing are up to a certain degree independent of the be-
haviour of the remaining volitional activities. We know
patients, who display great pressure of activity, but at the
same time are almost wholly mute, and on the other hand
those, in whom incapacity to make a decision is conjoined
with great pressure of speech, certainly also, as a rule, though
not always, with a certain restlessness. Moreover, we have
to distinguish between external and internal speech. The
observation, that taciturn patients make plays on words,
such as otherwise accompany pressure of speech with flight
of ideas, permits the conjecture, which is supported by the
self-observation of the patients, that here internal speech is
facilitated, while the transformation into movements of speech
appears to be inhibited. But lastly, as already indicated, writ-
ing may be facihtated, speech made difficult, and vice versa.

If we take into account the fact, that the development of
the partial disorders here indicated may pass through the
most various degrees in the individual domains of the psychic
life, the number of which might still be considerably
augmented, we have before us a sheer immeasurable multi-
plicity of clinical pictures, which may be compounded of
greater or less excitement or inhibition of one or other psychic
faculty. It would certainly be tempting to follow these
phases in detail. But, nevertheless I would emphasize the
fact, that such an analysis should not be given any too great
significance for chnical consideration. The overwhelming
majority of the actual morbid states display a relatively
simple structure, similar disorders in the larger domains of
psychic life, and may, therefore, be approximately brought
under the forms here delimited.

In the meantime it will be useful in the interpretation of
thie states to remember that in manic-depressive insanity
there is a large number of further possibilities without our
being obliged to assume morbid processes of other kinds. It
might be that here it is a case not so much of varieties of the
morbid processes as of personal peculiarities. We might,
perhaps, represent it thus to ourselves, that a further division
of work in the domain of the individual psychic faculties and
the resulting greater independence of partial domains might
also have as a consequence that these partial domains would
share in a different way and, to a greater or less degree, in the
general morbid process.

MIXED STATES • 115

The mixed states here described are with by far the great-
est frequency temporary phenomena in the course of the
disease. They pass over easily and often one into the other,
as one partial disorder is displaced by another. Most fre-
quently we meet with them, as already stated, in the tran-
sition periods between the two principal forms of the disease,
indeed, only from the history of their development, their
transformations from and to the known morbid states, do we
derive the justification to interpret them as mixed forms and
as states of manic-depressive insanity.

Moreover, mixed states may appear as independent mor-
bid attacks. And we see in the course of an attack of manic-
depressive insanity besides the simple states, states occasion-
all}^ attaining to development, which wholly, or at least pre-
dominantly, run their course in the form of mixed states. By
this naturally our conception of the essential identity of all
these clinical phases is confirmed. More often certainly the
different attacks of a patient seem to display the same mixed
state. When once such a state has appeared, there is a
certain probability that similar states will follow later. The
agreement of the individual morbid pictures, which in certain
circumstances are separated by decades, is often extra-
ordinary. In a case of manic stupor I was in the highest
degree astonished, when I had the old history sent to me from
another institution. Although the former attack had
occurred twenty-two years previously, the description given
at that time would have done just as well for the later attack
even in the smallest detail ; still ten years earlier a simple
depression had preceded.

The Course of mixed states occurring as independent
attacks appears in general to be hngering ; they might be
regarded as unfavourable forms of manic-depressive insanity.
They frequently occur in the later periods of the malady, in
which in any case the tendency to a prolongation of the
attacks is commonly seen.

The more exact knowledge of the mixed states makes it
possible for us to recognise the clinical significance of those
morbid pictures also which do not correspond with the principal
forms. Where the previous history presents orthodox manic
attacks or states of depression, the placing of the divergent
picture in circular insanity is naturally not difficult. On the
other hand those cases, which only display mixed states, may
cause very considerable diagnostic difficulties, especially at
the first attack. I know very well that even now it is still

ii6 MANIC-DEPRESSIVE INSANITY

often impossible to attain to a certain decision ; yet it
succeeds, certainly not too infrequentl}^ to recognise cor-
rectly from the fundamental disorders of manic-depressive
insanity, the composition of a pecuhar morbid state at first
incomprehensible and so to acquire important data for the
further course and issue.

CHAPTER VII.

FUNDAMENTAL STATES.

Manic-depressive insanity runs its course in attacks, whose
appearance is in general independent of external influences.
This fact shows us that the real, the deeper cause of the
malady is to be sought in a permanent morbid state which
must also continue to exist in the intervals between the
attacks. This assumption becomes specially illuminating
when frequent attacks return with approximately regular
intervals. But also when the disease appears only a few
times or even only once in a lifetime, its root must be sought
in a change of the psychic life, which is of long standing or
which has existed from youth up. At the first glance only
an exception is made by the cases in which the attack has its
origin in an external cause ; we shall later have to discuss how
this exception is only apparent, and why and how far.

The difference in frequency and violence of the attacks is
evidence that the severity of the change, which we pre-
suppose as the foundation of the whole morbid state, must
fluctuate within wide limits. The same thing is taught by
clinical observation. The great majority of manic-depressive
patients, especially of those with fewer attacks, display in the
intervals no divergence from average health ; although un-
doubtedly it might be possible that many peculiarities escape
the notice of the people round them, which, without being
exactly morbid, would yet to expert observation betray a
certain relation to their malady. But in a large series of cases
it is clear to the laity also and to the patient himself that per-
manently sHghter disorders of the general psychic condition
continue to exist, which in faint indications correspond to the
morbid phenomena of manic-depressive insanity. Among
almost a thousand cases observed in Munich such permanent
peculiarities were reported in about 37 per cent. Occasionally
the developed morbid attacks frankly appear only as an
increase of disorders which have already been present in the
whole former life ; more rarely they are conjoined with these
as complete opposites.

ii8 MANIC-DEPRESSIVE INSANITY

It is seen further that the permanent changes mentioned,
which essentially consist of peculiarities in the emotional life,
are not limited to individuals who suffer from attacks of
manic-depressive insanity. Their clinical significance would
be essentially impaired by this fact, if experience did not
teach that they are observed with special frequency as simple
personal peculiarities in the families of manic-depressive
patients. Even if that is not true for all cases, these re-
lationships are yet so frequent, that there can scarcely be
any doubt about their deeper significance. We are, there-
fore, led to the conclusion, that there are certain tempera-
ments which may be regarded as rudiments of manic-depressive
insanity. They may throughout the whole of life exist as
peculiar forms of psychic personality without further develop-
ment ; but they may also become the point of departure for
a morbid process which develops under peculiar conditions
and runs its course in isolated attacks. Not at all in-
frequently, moreover, the permanent divergencies are already
in themselves so considerable that they also extend into the
domain of the morbid without the appearance of more severe,
delimited attacks.

Classification. — On the grounds stated we consider
ourselves justified in incorporating in the group of the manic-
depressive "fundamental states" of our description besides
those morbid phenomena, which appear in the attacks, those
disorders also which on the one hand frequently accompany
the " free " intervals between the attacks, on the other hand
characterize the manic-depressive temperament in such cases
also in which the full development of the malady is absent.
The clinical forms, which would here perhaps have to be kept
separate, are principally the depressive temperament (" con-
stitutional moodiness "), the manic temperament (" con-
stitutional excitement "), .and the irritable temperament ;
along with these, mention would have to be made of those
cases in which moodiness and excitement frequently and
abruptly alternate with each other {cyclothymic tempera-
ment).

Depressive TtMPHKAMtNT.

The depressive temperament is characterized by a
permanent gloomy emotional stress in all the experiences of life.
Within the range of intellectual activity there is usually for
the most part no very striking disorder. A few patients are
even highly gifted, while in other cases mental development

FUNDAMENTAL STATES 119

has remained somewhat behind from youth up. Mental
efficiency may be good, yet the patients, as a rule, have to
struggle with all sorts of internal obstructions, which they
only overcome with effort ; they, therefore, are easily
fatigued. Moreover, they lack the right joy in work. Al-
though they are often ambitious and strive upwards with
success, they yet do not find complete, lasting satisfaction in
their work, as they keep in view the mistakes and deficiencies
of their achievements, as well as the approaching difficulties,
rather than the value of the thing accomplished. Therefore,
difficulties and doubts very easily press upon them, which
make them uncertain in their activity and occasionally force
them to repeat the same piece of work again and again. The
tendency to fruitless, especially hypochondriacal speculation
often exists. The patients " everywhere at once imagine
something." Their consciousness is always completely clear,
the connection of their thinking is in no wise disordered ; they
have a good understanding of the nature of their malady,
often also an extremely painful feeling of the difficulty caused
by their own insufficiency.

Mood is predominantly depressed and despondent,
" despairing." " I was on a small scale always melancholic,"
declared a patient, and a female patient said, " I brought
melancholy with me into the world." From youth up there
exists in the patients a special susceptibility for the cares, the
difficulties, the disappointments of life. They take every-
thing seriously, and in every occurrence feel the small dis-
agreeables much more strongly than the elevating and
satisfying aspects of untroubled and cheerful enjoyment, of
regardless surrender to the present. Every moment of
pleasure is embittered to them by the recollection of gloomy
hours, by self-reproaches, and still more by glaringly por-
trayed fears for the future. They " have never had any-
thing nice in the world," " I was always a child of ill luck,"
said a patient. Frequently, therefore, a capricious, irritable,
unfriendly, repellent behaviour is developed. The patients
are occupied only with themselves, do not trouble themselves
about their surroundings, display no pubHc spirit. Other
patients may to outward appearance be even-tempered and
may only reveal their unhappy emotional constitution, their
self-tormenting, to their nearest relatives or to the physician ;
when stimulated by external circumstances they are perhaps
cheerful, charming, and amiable, and even high-spirited, but
when left to themselves, they return again with a certain

120 MANIC-DEPRESSIVE INSANITY

satisfaction to their own introspective meditations on the
wretchedness of life.

Every task stands in front of them like a mountain ; life
with its activity is a burden which they habitually bear with
dutiful self-denial without being compensated by the pleasure
of existence, the joy of work. " I have always had to keep
myself together by force and not easily, and now it becomes
always more difficult," said a patient. The patients have
no confidence in their own strength, they have " very little
vital energy " ; they despair at every task, and become
anxious and despondent with extreme facility, they feel them-
selves of no use in the world, good for nothing, nervous, ill,
they fear the onset of a serious illness, especially mental
disorder, a disease of the brain. They are distrustful, regard
themselves as nature's step-children, are not understood by
their surroundings, and they like to occupy themselves with
thoughts of death, even already in childhood's years.

Many patients are constantly tormented by a certain
"feeling of guilt," as if they had done something wrong, as if
they had something to reproach themselves with. Sometimes
the things are real, but very remote or quite insignificant,
with which this tormenting uncertainty is connected. One
of my patients could not get quit of the thought of a sexual
offence committed years before. Another was not able to get
over the recollection of his landlady's having said that he
would never pass his examination. Although he succeeded
without special difficulty in passing, the thought constantly
persecuted him, that he had been a silly fool to let such a
thing be said to him ; everyone saw by the look of him that
he was a poor lot to take such things sitting down. Ever
again he was impelled to take steps in some way or other,
even after many years, to procure satisfaction for himself and
to restore again his honour, injured as he supposed.

The sexual domain in especial usually offers abundant
food for moodiness. The sexual emotions are roused very
early and lead to debauchery, but most frequently to
onanism, the consequences of which appear to the patients
in the blackest colours. A patient who by his inward excite-
ment was ever again, in spite of all vows and oaths, forced to
" necessary onanism," said of his state of dull hopelessness : —

" No human words can describe the suffering of soul, which this abomin-
able vice has caused me, and after I had gone through it, the word hell with
all its terrors lost all meaning for me, if it means anything else than the
consequences of onanism. To wander about as a living corpse, and with
fhat the consciousness of bearing the stamp of this vice, as it were, on thi

FUNDAMENTAL STATES 121

forehead and to hear the critical looks or even the cynical allusions of kind
friends, till one becomes so shy that one avoids going out during the day
and rather hides away in one's mouse-hole, till night begins ! By far the
worst is the horror and disgust at oneself, the feeling of hopelessness, which
becomes deeper at each fall, finally the cretinous resignation, the loss of
self-confidence ; one has no longer courage with the enemy in the camp."

Other patients also feel sexual excitement, which forces
itself on them in voluptuous pictures, most painfully, and all
the more if, through psychic impotence, through shyness, or
through moral considerations they are prevented from satis-
fying it. Here is a favourable soil for the development of all
sorts of singular expedients for help in this difficulty. Several
times I saw such fathers of families adopt measures for the
restriction of sexual intercourse or for the prevention of con-
ception, because they feared to injure themselves or shunned
the responsibility of bringing still more nervous children into
the world.

Not infrequently the emotional life is dominated by a
weak sentimentality, often with pronounced artistic and
belletristic inclination and ability. One of my patients
could not bear to read anything about the circulation of
blood ; he went to the slaughter-house in order to see what
he did when he ate meat, and thereafter adopted by prefer-
ence a vegetarian diet.

Conduct. — The whole conduct of life of the patients is
considerably influenced by their malady. On the one hand
appears their anxiety. " I may say that I was born in
anxiety," said a patient. They are without initiative, un-
certain ; they ask for advice on the slightest occasion. They
shrink from every responsibility, are afraid of the most
distant possibilities, weigh all details and consequences
scrupulously, avoid strictly all unusual, and still more,
dangerous matters. They must do everything themselves,
because they think that otherwise they cannot bear the
responsibility ; they use themselves up early and late in
trivial activity far more than is necessary, carry out every-
thing with tormenting precision and accuracy. A lady with
a very small household invariably in the evening used the
time from ten o'clock to half-past eleven to put in order her
few accounts for the day and so satisfy her duties as a house-
wife. The fear not to be able to earn a living, to fall into
want, causes many patients to practise exaggerated frugality.
They restrict their wants to the uttermost, they do not eat
enough and they let their clothes fall into disrepair.

In consequence of their anxiety the patients never come

122 MANIC-DEPRESSIVE INSANITY

to a rapid decision. They consider endlessly without carry-
ing out anything. A lady had first to be induced by the
summoning of a council of her whole family to consult a
physician, which she herself ardently wished to do, and even
then she could not make up her mind actually to follow the
advice given. The patients, therefore, continue at each task
and gradually arrive at an always narrower limitation of their
activity. They give up reading . and music, cycUng and
smoking, and do not go shopping any longer, because they
cannot make a choice, They cannot travel, because the
preparations, the decision where to go, are too difficult for
them. In the end even the drawing up of the bill of fare, the
oversight of the servants, the anxiety that everything in the
household shall be ready at the right time, are a very great
trouble. Many women cannot endure a strange face about
them, try to limit more and more the number of their
domestics, give themselves trouble to the uttermost. Finally
others let everything go as it will.

Examinations especially form an almost insurmountable
obstacle for our patients. In spite of very ample qualifica-
tions many a one renounces the higher career which beckons
him and contents himself with a modest Uttle place in Hfe,
because his deficient self-confidence and irresolution do not
allow him to take the necessary examination. Very often
caprices and peculiarities develop, which commonly have
some relation to the moodiness, and indicate measures by
which the patient tries to help himself over the inward diffi-
culties. The patients invariably have the inclination to
withdraw from intercourse with other people. They find no
joy in social life and pleasures, feel most comfortable when
they can commune with their own thoughts by themselves
or follow their artistic inclinations.

But it is especially their lack of self-confidence which pre-
vents them from cultivating personal relations. Compared
with other people who are perhaps otherwise far beneath them,
they appear to themselves awkward, boorish, foolish ; they
do not get rid of the tormenting feeUng that they are con-
tinually exposing their weak spot, that the people round them
look at them over the shoulder, that their presence is not
desired. A female patient said that she did not find time to
continue her education and must, therefore, appear stupid to
everyone. In consequence they become quiet and shy, avoid
their acquaintances on the street, live a solitary and secluded
life.

FUNDAMENTAL STATES 123

Suicide. — Many patients constantly play with thoughts
of suicide and are always prepared on the first occasion to
throw away their life. Although utterances of that kind are
not, as a rule, to be taken seriously, yet sudden suicides still
occur often enough among those morbidly ill-tuned patients.
A patient, when ten years old, ate verdigris, when thirteen
and again when twenty tried to hang himself, when fourteen
took strychnine, and when twenty-four shot himself in the
left breast, each time on a most trifling occasion.

Nervous Complaints. — ■ Frequently the patients are
tormented with all kinds of nervous complaints. They feel
tired, exhausted, complain of heaviness and dull pressure in
their head, unpleasant sensations in the most different parts
of their body, oppression, palpitation, congestion, pulsation,
twitching, vibration ; attacks of migraine are not rare. In
the sexual domain psychic impotence often exists and fre-
quent nocturnal emissions. The phenomena of nervous
dyspepsia are frequent ; digestion is usually sluggish. Sleep
is, as a rule, defective ; the patients have great need of sleep,
but fall asleep late, are frequently disturbed by starting and
by terrifying dreams, do not feel refreshed in the morning
but tired and unfit, and only in the course of the day do they
gradually become less uncomfortable.

Course. — The morbid picture here described is usually
perceptible already in youth, and may persist without essential
change throughout the whole of life. In isolated cases a
transformation of the disposition takes place first in the
years of development about the seventeenth, eighteenth, or
twentieth year, while up till then no specially conspicuous
deviations have appeared. Fluctuations also are later not
rare. Especially in connection with a violent emotion or a
bodily illness, but also without recognizable occasion the
state may become worse, and after a longer or shorter time
again improve somewhat. In rare cases once in a way after
a duration of decades a complete disappearance of the de-
pression appears to occur, as was reported by C. F. Meyer.
Now and then there are indications of a periodic course, but
the attacks are only very imperfectly delimited, and show a
tendency to run together in as far as the remissions become
always more indistinct. Occasionally psychogenic features
also appear, great need of comfort, reinforcement of the com-
plaints in the presence of the physician. " She is quite happy,
so long as she does not associate with those women who also
think that they are ill," wrote the husband of a patient.

124 MANIC-DEPRESSIVE INSANITY

It is exactly the fluctuations of the state progressing im-
perceptibly to real attacks, which point to the inner relation-
ship of the depressive temperament with manic-depressive
insanity.^ There is actually an uninterrupted series of
transitions to " periodic melancholia," at the one end of
which those cases stand in which the course is quite indefinite
with irregular fluctuations and remissions, while at the other
end there are the forms with sharply defined, completely
developed morbid picture and definite remissions of long
duration.

But further, the fact is of the greatest significance, that
the depressive state may be very suddenly interrupted by
manic attacks, indeed that it not very rarely forms the
foundation on which the morbid state of " periodic mania "
is developed ; still more frequently an alternation of manic
and depressive attacks occurs. We found the depressive
temperament in 12.1 per cent, of our manic-depressive cases,
but this proportion is certainly considerably too low because
of the incompleteness of our histories of the patients. Lastly,
the great clinical similarity of the picture here drawn with the
slightest forms of depressive attacks must be pointed out.
The shyness, the lack of self-confidence, the dejection, but
especially the feeling of inward obstruction in thought and
will, the irresolution, the hypochondriacal fears and thoughts
of suicide are found in both morbid forms in quite similar
manner.

Both the agreement of the states and the close clinical
relations of the depressive temperament to manic-depressive
insanity, and its place in the inherited series scarcely leave any
doubt, therefore, that we have here to do with a rudiment of
the fully developed disease. To that must still be added the
circumstance, that we shall immediately become acquainted
with a manic temperament which completely corresponds.
The possibiHty must, however, be left open, that not all forms
of depressive temperament are to be interpreted in the same
sense. Thus specially the cases with more definitely de-
limited states of anxiety and fear might not belong to this
form, and here also there is not usually any lasting, un-
changing depressive moodiness nor any general inhibition.

On the other hand it appears to me that with the states
here deHneated certain tender and gentle natures a Uttle in-
clined to melancholy are inwardly related. These are often

' Reiss, Konstitutionellc Verstimmung und manisch - depressives
Irresein, 1910.

FUNDAMENTAL STATES 125

found in families with manic-depressive disposition, and
sometimes these individuals actually fall ill. There are
people, especially women, who combine anxiety, scrupulous
conscientiousness, and lack of self-confidence with good in-
tellectual endowment, attractive, clinging amiabilit}^ and
great goodness of heart, who shun every rough contact with
life, who easily make cares for themselves, who understand
well how to endure, indeed to sacrifice themselves, but not
how to fight. Not infrequently they display deficiency of
the sense of reality, unworldhness and a tendency to visionary
moods, occasionally perhaps also a surprising violence.

Manic Temperament.

The manic temperament which I formerly described
as " constitutional excitement " forms the antithesis Of the
depressive temperament ; more recently it has been de-
scribed in greater detail, especially by Specht and Nitsche.^
The intellectual endowment of the patients is for the most
part mediocre, sometimes even fairly good, in isolated cases
excellent. They acquire, however, as a rule, only scanty,
and, in particular, very imperfect and unequal knowledge,
because they show no perseverance in learning, do not like
exerting themselves, are extraordinarily distractible, and
seek to escape in every way from the constraint of a
systematic mental training, and in place of that they pursue
all possible side-occupations in variegated alternation. " She
can do everything well when she likes," reported the re-
latives of a patient. Not infrequently they possess a very
good faculty of perception and remember details without
difficulty. But their understanding of life and the world
remains superficial, the mental working up of their experi-
ences bleared and indistinct, the remembrance of former
events fleeting, coloured by partiality, and falsified by
numerous personal additions. The train of thought is
desultory, incoherent, aimless ; judgment is hasty and
shallow. The patients are not concerned about their past,
their surroundings, their position, their future, have in
general no need to account for the circumstances of life or to
form a general view of life.

Mood is permanently exalted, careless, confident. The
patients have very marked self-confidence, put an extremely
high value on their own capabilities and performances, boast

1 Specht, Zentralblatt f. Nervenheilk., 1905, 590; Nitsche, Allgem.
Zeitschr. f. Psj/ch., Ixvii, 36.

126 MANIC-DEPRESSIVE INSANITY

with the most obvious exaggeration. They wholly lack
understanding for the morbid imperfection of their tempera-
ment. Rather are they convinced of their superiority to their
surroundings, are proud of their ideal sentiments, their re-
fined accent, their depth of feeling, and they confidently
expect to make their fortune by their excellent endowment.
Towards others they are haughty, positive, irritable, im-
pertinent, stubborn. They show little sympathy witli the
sorrows of others ; they enjoy deriding, teasing, and ill-
using those who. they think, are their inferiors. When
contradicted they may be extremely rough and coarse, but
in certain circumstances accept even great reproaches and
insults with surprising equanimity without understanding
the mortification properly. They are usually ready for jokes,
even for self-derision, for conversation and pastimes of all
kinds and for all sorts of tricks. Now and then once in a
way anxious or mournful moods also may temporarily be
present.

In the Conduct and the Activities of the patients a
certain unsteadiness and restlessness appear before every-
thing. They are accessible, communicative, adapt them-
selves readily to new conditions, but soon they again long
for change and variety. Many have belletristic incHnations,
compose poems, paint, go in for music. A patient spoke of
writing up the fortunes of his fellow-patients as novels. They
like picturesque and conspicuous clothes, wear a fez, or they
neglect themselves and run about in rags and dirt. Their
mode of expression is clever and lively ; they speak readily
and much, are quick at repartee, never at a loss for an answer
or an excuse, although often only a very threadbare one.
" She can speak and read like a lawyer, when she likes," was
said of a young girl.

In conversation the patients assume a free and easy tone,
give pert or ironical answers, use choice poetical phrases,
quotations, sought-out allusions, or they talk in forcible
language, in coarse dialect ; they weave in equivocations and
poor jokes, which they accompany with roaring laughter.
Whenever they are irritated, they usually make use of a very
comprehensive " Dictionary of Abuse," to use Specht's ex-
pression. " She has an extraordinarily foul mouth," was the
expression used to describe a patient. What they write is
verbose, prolix, bombastic, full of personal remarks,^^
witticisms, insulting sallies. Frequently they perforn|H
peculiar and conspicuous actions. A patient had " Pray and

FUNDAMENTAL STATES 127

work " printed on his card after his name. Another accosted
people on the street and asked them if there is a God, and if
they had ever thought of dying.

In making decisions the patients are desultory and un-
certain. In consequence their life is invariably a chain of
thoughtless and extraordinary, not infrequently also non-
sensical and doubtful activities. Already at school they are
insubordinate and disorderly, ring-leaders in all disturbances
of the peace ; they play truant, run away, do not get on any-
where, have to change their school, fail in examinations,
because of their aversion to thorough and persevering study.
They stand military discipline very badly, neglect cleanliness
and order, overstay their leave, are remiss in service, resist
authority, and are, as a rule, often punished, when it is not
recognized that they are ill. At the same time an important
part is frequently played by the sexual instinct which awakens
early and is very active, and which leads them to debauchery.
Female patients almost of necessity fall a prey to prostitution.
The influence of alcohol is usually still more unfavourable,
to which, in general, they yield themselves without resist-
ance ; the patients spend in drinking and conviviahty all
that they can get hold of. One of my patients became a
morphinist ; others are great smokers and snuffers.

Further, it now comes to the most varied attempts to
attain to some position in life, and the patients often go about
it not without ability, but without perseverance. Without
sufficient reason they change calling and position, are always
beginning something new, make large plans and after a short
time drop them again, and get into all kinds of low company.
A clergyman invented a new card-game and passed his time
in fishing and photography ; he overwhelmed his superiors
with suggestions for improvements in the church. Others
wish to become missionaries, or to go to America. Many
patients join new movements with fervent zeal which rapidly
flags, become ardent vegetarians, anti- vaccinators, anti-
Semites, sportsmen, bathe in the cold of winter ; others
become cheap jacks, professional jokers, town originals.
They often attempt tasks to which they are in no way equal,
make purchases far beyond their circumstances, decorate
themselves with high-soundmg titles, to which they have not
the least claim, try to gain respect by boasting and swagger-
ing. A patient had a crown printed on his; visiting cards.

The aimlessness of their procedure is sometimes very
peculiar ; it distinctly shows how little the: inner pressure of

128 MANIC-DEPRESSIVE INSANITY

activity is guided by sensible deliberation. One of my
patients had inflated advertisements of various chemical
products printed at great expense, sent them all over the
world, and entered into contracts for deUvery of the goods,
although he, as a former dealer in fancy goods, knew nothing
at all of chemistry, concocted his materials on a common
kitchen-range, and was quite unable to manufacture the
large quantities ordered. He said that he had first just
wanted to see whether buyers would come at all, before he
really made arrangements for production. A few patients
have really good ideas, make useful inventions, display great
business ability, but yet on account of their unsteadiness and
unrehability and also on account of their scattering their
resources in all possible enterprises have never any success.

With their surroundings the patients often Uve in con-
stant feud. They interfere in everything, overstep their
rights, make arrangements which they are not entitled to
make. As they do not fulfil their obligations, but at the
same time make great claims and behave arrogantly, they are
soon dismissed from their posts. They then become in-
volved in legal processes for compensation and bring actions
for damages, but everywhere they put themselves in the
wrong by the immoderation of their procedure. Sometimes
they fall into a veritable entanglement of lawsuits, which
they pursue with ardour and with vigour through all the
courts of appeal. They show no respect to their superiors,
their manners are churUsh, they will not be taught, they
respond to regulations with poor jokes or abuse. They have
no understanding whatsoever for the unseemliness of their
behaviour ; they do not comprehend at all why everything
they do is taken amiss, are astonished in the highest degree
at the compUcations which arise, but get over it with a few
jests. A clergyman who had called his opponent " Hansw,"
[Hanswurst — Merry-Andrew] and " Rind v." [Rindvieh — ■
cattle] on a post card, asserted quite naively, when he
was prosecuted, that that meant " Hanswief " and
" Rindvogelein " ■; no one had the right to read anything
else into it than what he had meant.

As everywhere they prove themselves useless, the patients
invariably fall into financial difficulties. When their means
are exhausted, they begin to borrow, to raise money on
credit, to run up bills at public-houses, to defraud. To raise
their credit they have at their service their great hopes for
the future, an almost completed invention, an appointment

FUNDAMENTAL STATES 129

which they have in view, their acquaintance with highly-
placed individuals, an impending marriage which will bring
them money, an assumed title. When rebuked, they assert
indignantly that they are quite in the right, that they have
not had the slightest intention to defraud, but that in a short
time they will be able to satisfy all their obligations. Im-
mediately after the reproof their former practices begin again,
till at last, often only after decades, the morbid foundation of
this extraordinary and incoherent conduct of life is re-
cognized. " People, who do not know her, just call her gay,"
was what the very intelligent mother of a patient wrote to us.

The points of contact of this morbid picture with slight
hypomanic states are, as I think, unmistakable. But the
excitement here is still more slightly indicated, and it does
not run its course in circumscribed attacks, but it is a per-
manent personal peculiarity. Certainly the clinical picture
often develops more distinctly first in the years of develop-
ment, in certain circumstances in the form of a transforma-
tion from a period of youth with a more depressive colouring.
Further, not infrequently a certain progressive development is
seen. Nitsche has described cases as " progressive manic con-
stitution," in which a sHghter manic predisposition develops
towards the fiftieth 3^ear into a pronounced hypomania.
Fluctuations of the state also are frequently observed ; in
certain circumstances they may progress to the development
of sUghter or more severe manic attacks. Just as often does
it come to the appearance of alternating manic-depressive
states ; more rarely states of pure depression are inter-
polated. A slight, quickly passing transformation of mood
is still fairly frequent ; occasionally it may come to a suicidal
attempt. Of the manic-depressive patients observed in
Munich about 9 per cent, showed a manic predisposition.

The slightest forms of the disorder lead us to certain
personal predispositions still in the domain of the normal.
It concerns here brilliant, but unevenly gifted personalities
with artistic inclinations. They charm us by their in-
tellectual mobility, their versatility, their wealth of ideas,
their ready accessibility and their delight in adventure, their
artistic capability, their good nature, their cheery, sunny
mood. But at the same time they put us in an uncomfort-
able state of surprise by a certain restlessness, talkativeness,
desultoriness in conversation, excessive need for social life,
capricious temper and suggestibility, lack of reliability,
steadiness, and perseverance in work, a tendency to building

130 MANIC-DEPRESSIVE INSANITY

castles in the air and scheming, occasional unusual activities.
Now and then one possibly hears also of periods of causeless
depression or anxiety, which usually are traced back to ex-
ternal circumstances, over-work, disappointment >. Tliis ex-
perience, as also the further circumstance, that we very often
see the parents, brothers and sisters, or children end in
suicide, in mournful moodiness, or even fall ill of definite
manic-depressive insanity, suggests to me that that kind of
strongly developed sanguine temperament is to be regarded
as a link in the long chain of manic-depressive predispositions.

Irritable Temperament.

The irritable temperament, a further form of manic-
depressive predisposition, is perhaps best conceived as a
mixture of the fundamental states, which have been described,
in as much as in it manic and depressive features are
associated. As it was demonstrable in about 12.4 per cent, of
the patients here taken into account, it appears to be still a
little more frequent than the depressive predisposition. The
patients display from youth up extraordinarily great fluctua-
tions in emotional equilibrium and are greatly moved by all
experiences, frequently in an unpleasant way. While on the
one hand they appear sensitive and inclined to sentimentality
and exuberance, they display on the other hand great irrita-
bility and sensitiveness. They are easily offended and hot-
tempered ; they flare up, and on the most trivial occasions
fall into outbursts of boundless fury. " She had states in
which she was nearly delirious," was said of one patient ;
" Her rage is beyond all bounds," of another. It then comes
to violent scenes with abuse, screaming and a tendency to
rough behaviour. In such an attack of fury a female patient
threw a whole pile of plates on the ground ; she flung a lighted
lamp at her husband and she tried to attack him with the
scissors. The patients are positive, always in the mood for
a fight, endure no contradiction, and, therefore, easily fall
into disputes with the people round them, which they carry
on with great passion. A female patient who thought that
she had been taken advantage of in the purchase of a house,
threatened her opponent with a revolver, which, however,
was unloaded. In consequence of their quarrelsomeness the
patients are mostly very much disUked, have frequently to
change their situations and places of residence, never come
well out of anything. A patient who was an officer fought a
series of duels with swords. In the family also they are

FUNDAMENTAL STATES 131

insufferable, capricious, threaten their wives, thrash their
children, have attacks of jealousy.

Mood. — The colouring of mood is subject to frequent
change. In general the patients are perhaps cheerful, self-
conscious, unrestrained ; but periods are interpolated in
which they are irritable and ill-humoured, also perhaps sad,
spiritless, anxious ; they shed tears without cause, give ex-
pression to thoughts of suicide, bring forward hypochon-
driacal complaints, go to bed. At the time of the menses the
irritability is usually increased.

Intellectual endowment is often very good ; many
patients display great mental activity, and they feel keenly
the necessity for further culture. But they are mostly very
distractible and unsteady in their endeavours. Sometimes
they are considered to be liars and slanderers, because their
power of imagination is usually very much influenced by
moods and feelings. It, therefore, comes easily to delusional
interpretations of the events of life. The patients think that
they are tricked by the people round them, irritated on
purpose and taken advantage of ; occasionally they imagine
there is poison in their food. On the other hand they build
castles in the air, take themselves up with impracticable
plans.

Capacity for work may not show any disorder worth
mentioning ; many patients are very diligent, indeed over
busy, over zealous, but yet accomplish relatively little. In
conversation the patients are talkative, quick at repartee,
pert. In consequence of their irritabihty and their changing
moods their conduct of life is subject to the most multi-
farious incidents, they make sudden resolves, and carry them
out on the spot, run off abruptly, go travelling, enter a
cloister. A female patient " became engaged, before she
realized what was happening." Psychogenic disorders are
often conspicuous, convulsive weeping, fainting fits, cramps.

Cyclothymic Temperament.

The cyclothymic temperament must still be shortly
considered. It is characterized by frequent, more or less
regular fluctuations of the psychic state to the manic or to the
depressive side. It was found only in 3 to 4 per cent, of our
patients, but without doubt in reality is much more frequent,
as it is the invariable introduction to the slightest forms of
manic-depressive insanity which run their course outside of
institutions, and frequently leads to them by gradual

132 MANIC-DEPRESSIVE INSAMTV

transitions. These are the people who constantly oscillate
hither and thither between the two opposite poles of mood,
sometimes " rejoicing to the skies," sometimes " sad as
death." To-day lively, sparkling, beaming, full of the joy of
life, the pleasure of enterprise, and pressure of activity, after
some time they meet us depressed, enervated, ill-humoured,
in need of rest, and again a few months later they dis])lay the
old freshness and elasticity.

" I have always throughout life imagined sometliing,"
explained a patient, " one time I thought that everything was
soaring, another time it appeared to me as if the sky were
falling in." Another stated that she had times, in which
" everything got on so well from herself outwards," and other
times, in which " again everything was so frightfully diffi-
cult." A third said that she was " like a barometer, one
time so, another time different." A patient described how
sometimes at his work " each grip was difficult," and how
then a " lightening of the brain " came over him.

Wilmanns draws attention to artists, who are only at
certain times happy in creating and productive, and in the
intervals in spite of all efforts do not get beyond unsatisfying
attempts. At first these deviations from the middle line are
only occasionally perceptible once in a way and as rapidly
passing attacks ; but for the most part they have the
tendency to return more frequently and to last always longer,
indeed finally to fill up the whole fife.

CHAPTER VIII.

FREQUENCY OF THE INDIVIDUAL FORMS-
GENERAL COURSE.

The frequency, with which the different chnical forms of
manic-depressive insanity here described occur in a fairly
large series of observations, is naturally very various. The
slight forms are excluded from such a view, as the}/ only
rarely come to institutions, but are usually treated in the
family or in all possible sanatoria. Their number is extra-
ordinarily large. There is no " Nursing Home for Nervous
Cases," which has not constantly had a whole series of them
as inmates, certainly for the most part under the terms, over
work, nervousness, neurasthenia, hysteria, and so on.
Among the patients who came to our hospital 48.9 per cent
presented states of depression only, 16.6 per cent, manic
attacks only, and 34.5 per cent, a combination of manic and
depressive morbid phenomena, sometimes one after the other
sometimes alongside each other. Then it has, of course, to
be taken into account that the course of the disease in the
very great majority of cases was certainly not nearly at an
end. If only cases were taken into account, which died in
advanced age, the number of the combined forms would with-
out doubt be very considerably increased.

Among the simple forms states of depression in the form
of melancholia simplex and gravis with 23.5 per cent, are the
largest group ; in a further 13.5 per cent, there were extra-
ordinary delusions, and in still other 6.1 per cent states of
anxiety were present. Slight manic excitement was present
in 4 per cent of the cases, acute mania in 9.8 per cent. States
of confusion and stupor of various colouring occurred in 8.2
per cent., compulsive ideas in i per cent. Among the com-
bined forms the slighter forms predominated with 10.6 per
cent, against the more severe with 9.1 per cent. States of
stupor and clouding of consciousness were seen in 4.9 per
cent ; more definite delusions likewise in 4.9 per cent. A
comparison, which Walker ^ gives, is drawn up, indeed, from

1 Walker, Archiv f. Psychiatric, xlii. 788.

134 MANIC-DEPRESSIVE INSANITY

other points of view, but in the main is not very divergent.
He found among 674 cases in men 55.7 per cent melancholias,
II per cent, manias, and 33.3 per cent, circular cases, in the
women 70.2 per cent., 6.2 per cent., and 23.6 per cent.

The individual attacks of manic-depressive insanity, as
already appears from the clinical description, are not all the
same, but may have very different forms. If one wishes to
classify, one may first separate out those forms, in which all
the attacks exhibit the same colouring and those in which an
alternation of states takes place. To these last the mixed
states would be added, in as much as they come to develop-
ment by far the most frequently in transitions of that kind.

Here it must meanwhile be emphasized, that this classi-
fication, apparently so simple, really encounters manifold
difficulties. Firstly, it will always be doubtful in the case ot
patients still living, whether a series of similar attacks even
after a duration of decades will yet not be unexpectedly in-
terrupted by a state of quite a different kind. But then also
the characterization of individual attacks is very often by no
means simple. In the enormous majority of manias, as soon
as attention is directed to it, states of depression either at the
beginning or the end are observed, which certainly last only a
few days and may be little marked. In the course of excite-
ment also hours or days of opposite colouring are interpolated
with extreme frequency, and finally it turns out often enough
that slight moodiness has been present in tlie intervals be-
tween the manic attacks. On the other hand the states of
depression which belong to this class are often followed by a
remarkable " reactionary " cheerfulness which by physicians
and patients is generally regarded as an expression of pleasure
at recovery, as the reactionary " melancholia " after mania
is regarded as exhaustion or as sorrow about the mental dis-
ease which has been passed through. During the depression
we observe states of sudden excitement, transitory merri-
ment, or we learn that the patients have either fonnerly or
afterwards decorated themselves in a conspicuous way, have
contrary to their usual custom visited places of pleasure, have
been irritable and excited.

If, therefore, for the sake of having a general view we
classify the attacks according to their colouring, we must at
the same time not forget that here it does not at all concern
fundamental distinctions. But rather, just as in the states
of excitement and depression in paralysis or dementia praecox,
all the pictures only represent the changing phenomena of one

FREQUENCY OF INDIVIDUAL FORMS 135

and the same fundamental morbid process, which may be
connected with each other in the most multifarious ways and
pass over one into the other.

A first survey over the general course of manic-depressive
insanity gives the following classification in which 899 cases
are arranged first according to the colouring, then according
to the frequency of attacks. With regard to the former, three
groups were made, according to whether the cases ran their
course as depression, or as mania, or lastly, in both forms or
in mixed forms. Next the cases were classified with only one
attack, with two attacks, or with three or more attacks. As
the observations were naturally, as regards the greatest
number of them, not concluded, it would be expected that
still considerable displacements with regard to the number
of the cases would take place, yet even so perhaps a
comparison between the different forms is not without
value : —

Depression.

Mania.

Combined Forms.

One attack . . . 263

102

106

Two attacks . . . 120

Three and more attacks 57

115

This summary shows first that in a fairly large series of
observations depression occurring once has a great pre-
ponderance. Here the fact has to be noted, that the majority
of all cases of manic-depressive insanity, about 60 to 70 per
cent., begin with a state of depression. This first attack,
which, as a rule, runs a mild course, is followed in about two-
thirds of the cases by a free interval, which in certain cir-
cumstances may last throughout life. In about one-third of
the patients, however, manic excitement immediately follows
depression, and in most cases leads on to temporary re-
covery. Only in a small number of cases depression now
begins again immediately, and again gives place to excitement
and so on.

The number of the attacks, which are repeated in similar
form, is in the first group comparatively small ; three and
more depressive attacks were about four to five times more
rare than single attacks. The cause of that is obviously that
a great number of patients only fell ill once or at the time of
observation had only their first attack behind them, Pro-
ably, however, many of the single attacks of depression would
in the course of time turn out to be the introduction to com-
bined forms. At least the circumstance is in favour of this.

136 MANIC-DEPRESSIVE INSANITY

that among the patients, in whom three and more attacks
were recorded, the combined forms were by far the most often
represented.

When the disease begins with a manic attack, a remission
appears next, Hkewise in approximately two-thirds of the
cases ; in the remaining cases moodiness or stupor im-
mediately follows excitement. Here a similar repetition of
the attack at first appears still considerably less frequent than
in states of depression ; on the other hand, if it does follow,
one may reckon with greater probability than in depression
that still more similar attacks will follow. But on the whole
with an increasing number of attacks the tendency evidently
becomes greater to a change of colouring or to an admixture of
morbid phenomena of other kinds. Generally speaking one
certainly observes that the individual attacks in a patient
present a certain similarity with each other, which may now
and then rise to " photographic " similarity. But there is
very frequently the opportunity in the course of the same
disease of seeing quite a number of the states described here
appear one after the other from slight depression and stupor
through the most multifarious mixed states to hypomania and
to acute mania. Up to now I have not succeeded in finding
any rule to which they conform. (Jii particular a quite
regular alternation between manic and depressive morbid
periods, of the kind to which the attention of alienists has
been mainly drawn, belongs to the rarer exceptions. The
grouping is mostly irregular, as we shall see later in more
detail in some examples. Often enough it also occurs that
in a whole series of similar attacks a single one of opposite
colouring is interpolated. Frequently a more regular alterna-
tion is developed after a somewhat long duration of the
disease, when in the first part of the disease one kind of attack
predominated or was alone present. The mixed forms also,
especially manic stupor, come to development, as it appears,
usually first after repeated attacks.

The duration of individual attacks is extremely varied.
There are some which last only eight to fourteen days, indeed
we sometimes see that states of moodiness or excitement,
undoubtedly morbid, do not continue in these patients longer
than one or two days or even only a few hours. For the
most part, however, a simple attack usually las cs six to eight
months. On the other hand, the cases are not at all rare, in
which an attack continues for two, three or four years, and a
double attack double that time. I have seen manias, which

FREQUENCY OF INDIVIDUAL FORMS 137

even after seven years, indeed after more than ten years, re-
covered, and a state of depression, which after fourteen years
recovered. Albrecht reports a case of melancholia, which
after eighteen years passed over into mania. The duration
of the first attacks is not usually longer than a few months,
while later on it usually extends more and more, in certain
circumstances by the confluence of several attacks.

Almost always there are free intervals between each two
simple or double attacks. The duration of these is likewise
subject to extraordinary fluctuation ; it may extend from a
few weeks or months to many years and even to several
decades. Among 703 intervals, which I have compared,
there were 96, which lasted 10 to 19 years, 34, 20 to 29 years,
8, 30 to 39 years, and i, 44 years. Dupouy observed inter-
vals of 25 and 30 years. Vedrani has collected a series of
cases with long intervals. He reports a mania, which after
26 years was followed by three more short manic attacks, an
attack of combined depression, stupor, and mania, with a
mania following after 27 years, and a similar case with
depression after 42 years. He further mentions a case of
mania and depression with a mixed state after 27 years, two
depressions with pauses of 32 and 35 years, two manias with
pauses of 21, 30, 35 and 44 years, lastly, the sequence of
mania-depression or vice versa with pauses of 33 and 36 years.
Hiibner reports a case of mania, in which after a first pause
of 41 years a regular return of the attacks followed ; in
another case the time between the second and third attacks
was 44 years.

A definite relation between the duration of the attacks
and the intervals does not seem to exist. Short attacks may
be repeated in rapid succession, but may also be interpolated
one at a time in fairly long free intervals. Prolonged and
severe attacks on the one hand probably leave behind an
increased tendency to fresh attacks ; but, on the other hand,
it is also often seen that it is these very attacks which are
followed by a longer pause. Sometimes the duration of the
intervals is so invariable, that at the usual time the patients
return punctually to the institution ; but for the most part
the disease shows the tendency later on to run its course more
quickly and to shorten the intervals, even to their complete
cessation. At the same time the duration of the attacks
usually increases gradually. Thus I saw in one case in the
course of thirteen attacks the duration of these increase from
three or four months up to six or seven, while the intervals

138 MANIC-DEPRESSIVE INSANITY

decreased from one year to six or seven months. But even
in spite of long duration of the disease an attack may once in
a way run its course with unexpected rapidity, especially in
the forms with long intervals. In the years of involution the
intervals readily decrease and occasionally are again
lengthened later on.

I have tried to form a somewhat more precise idea of
these relations by finding the duration of the individual
intervals in 406 cases with two or more attacks. By classify-
ing according to their length the median was determined, that
duration which in such a series lies exactly in the middle. In
this way we get a more correct picture than by reckoning an
arithmetical average, which is influenced unduly by un-
usually long intervals. The interval between attacks follow-
ing each other was according to this reckoning as follows : —

Interval

. I

II III

V and following

Years .

• 4-3

2.8 1.8

1-5

No. of cases.

. 406

157 64

The shortening of the intervals, at first rapid then slower,
with the number of the repetitions is clearly seen in this
summary. At the same time it has to be remarked that a
series of observations, with very frequent attacks and short
intervals, could not be taken into account because the times
were not certain. The clinical form of the disorder stands
in clear relation to the length of the intervals, as the following
survey shows, in which the number of the cases made 'i«> '^f
each time is added in brackets : —

Intervals .... I II

III and more

States of Depression Years 6(167) 2.8(46)
Manic States „ 3.3 (53) 4.5 (24)
Combined States „ 3-4(185)2.6(87)

2 (27)
2 (20)
1-5 (98)

The first return of depression is. therefore, to be expected
after a considerably longer space of time than that of mania
or of a combined attack. This result is certainly influenced
by the not infrequent cases, in which depression appears in
the age of evolution and then first returns again in the years
of involution, sometimes repeatedly, or in alternation with
manic attacks. The later relapses also appear to run a some-
what slower course than those of the combined forms. The
number that falls out of the series for the second interval in
manic cases might be owing to an accidental mistake on
account of the small number of observations at our disposal.

FREQUENCY OF INDIVIDUAL FORMS 139

In the remainder the shortening of the intervals with the
number of attacks is everywhere distinct.

At times the malady begins with a closed series of very
short attacks following very quickly one after the other of
manic or manic-stuporous colouring, which is then followed
by a longer pause of several years. That is especially the
case in a small group of youthful patients, preferably, as it
seems, women. The individual states of excitement often
last then only a few days, but may be very violent and be
accompanied by great confusion. Only a small minority,
probably not more than four to five per cent., is made up by
the cases, in which the disease steadily and completely fills
the whole life from the first attack onwards in regular alterna-
tion of colouring. Repeatedly I saw in these cases moodiness
set in in autumn and pass over in spring, " when the sap
shoots in the trees," to excitement, corresponding in a certain
sense to the emotional changes which come over even healthy
individuals at the changes of the seasons. As a rule, it might
there be a case of forms with a very slight course, hypomania
and simple inhibition. Even after a considerably long, un-
interrupted course, however, a fairly long remission may after
all still occasionally make its appearance.

The different varieties of course taken by manic-depressive
insanity, as they are conditioned by the changing behaviour
in duration and colouring of the individual attacks, as well
as in the length of the intervals, have been analysed into a
series of clinical sub-varieties, specially by Falret and Bail-
larger, who first made us more intimately acquainted with
this disease ; these sub-varieties are intermittent mania and
melancholia, regular and irregular type, folie alterne, folie a
double forme, folie circulaire continue. I think that I am con-
vinced that that kind of effort at classification must of
necessity wreck on the irregularity of the disease. .The kind
and duration of the attacks and the intervals by no means
remain the same in the individual case but may frequently
change, so that the case must be reckoned always to new
forms.

In order now to give a more exact view of the varieties of
course in manic-depressive insanity, I reproduce a number of
diagrams, each of which represents the life of a patient ; they
were mostly sketched out by Rehm. Blue signifies de-
pression, red manic excitement, both colours being shaded
according to the severity of the morbid phenomena. The
mixed states were, as far as possible, signified by hatching.

140

MANIC-DEPRESSIVE INSANITY

Blue hatching towards the left on a red ground signifies raving
mania, towards the right manic stupor, red hatching on a
blue ground depression with flight of ideas, cross hatching
depressive excitement. The first normal decades were left
out in order to save space.

The first case (Fig. 22) represents a periodic depression
with almost qyite ]^egular intervals, in which curiously in a
later attack excitement, appeared at times. With the ex-
ception of the first, which has a more rapid course, the attacks

<•

Alter

JiODir

Febr.

Mirz

April

Mtl

J^nl

Jail

Avgnst

Sept.

Okt.

No*.

.^11

■ ,

'U]

^^^

^__

_^_

__^

^__

_^_

f —

^^*

^^"

^^^

'^^

___

^^_

Rfl

^^^

^^_

^^*

^^^

^^*

Fig. 22. — Periodic Depression (i).
Mairfe HB \//A ZornlKC Manie

Hypomanie I I KWl Miolscher Stupor

Schwere j ^^| [xyd Depression mit Erregnng

\ Depression
Leichte I 1 I E3 DeprtssioD mit Reirbarkeit

have almost exactly the same duration. In the second case
(Fig. 23) which likewise represents only depression, here also
with admixture of excitement in the later attack, we see the
disease begin at the age of sixteen. Then follows a pause
lasting almost twenty-six years up to the forty-second year,
the approach of the cUmacteric, which brings with it two short
attacks, the one following close on the other. The third case
(Fig. 24) again runs its whole course in depression, which here

FREQUENCY OF INDIVIDUAL FORMS 141

Alter

Januar

Febr.

Marz

April

Mai

Juni

Juli

Augusi

Sept.

Okl.

Nov.

Dei.

f"'

•*fe^

r'll

'•^11

'til

X feX AJ^^XKAXK J

B^£=

rxxx

Fig. 23. — Depression in youth and in involution (2).

Alter

Jannar

Febr.

Marz

April

Mai

Juni

Juli

August

Sept.

Okt.

Nov.

Dei.

^^^

jU-

^^^

X>^

S?^ >

Yt Y

, Y\>

K ^

^}^

>cx.

- - -

y y,

?^x>;

IWb^

XV"}

"X y

!s xy

}^^

K^><.

Fig. 24. — Frequent Depression. (3)

Alter

Jaonar

Febr.

Marz

April

Mai

Joni

Juli

August

Sept.

out.

Not.

Dez.

:f\

i^XX.'

XXX

<y.x.:

X"^

i. >^y

yv->

'1^'^

)<K

^>c >

><.x>

J'.'x:

Fig. 25. — Periodic Depression after isolated manic attacks (4).

142

MANIC-DEPRESSIVE INSANITY

also is accompanied in the later attacks by excitement. It
begins first in involution at the age of forty-nine ; then follow
with decreasing intervals three similar attacks.

Alter

Januar

Ftbr.

Marz

April

Mai

Juni

Juli

Aufiuil

Scpl.

Olil.

Nov.

Dei.

:^s

'DJ.

K X

* X

?^^

|^>C

^. 7*. .^ ^/^

fi)*.)

.^^

A/VN

Vv>

aK/

vV\

/yv

vy"

/vs

VV"

/\/\.

s/S

Fig. 26. — Chronic Depression (5).

The fourth case represents another picture. The first
short depressive attack in the twenty-first year is followed by
a pause of more than fourteen years. Then begins a series of
attacks, mostly short but some of them fairly long, with short

Alter

Janoar

ftbr.

Mart

April

Mai

Juni

Jali

ABgnsI

Srpt.

Okl.

.No».

Oei.

'ill

I 1

■Be

^11

ta-r ■

_. _

]

-j

. .

hll

„

V-v

Fig. 27. — Periodic Mania (t).

irregular intervals. The majority of these attacks, ten, arc
depression, partly, especially the last one, with excitement.
But among these, two slight manic periods running a short
course are interpolated as first indication of a transition to the

FREQUENCY OF INDIVIDUAL FORMS 143

circular form. The last of the depressive cases (Fig. 26)
shows a single attack of depression lasting almost fifteen
years, but still resulting in recovery. It betrays its place in
manic-depressive insanity not only by a favourable issue, but

Alter

ianaar

Febr.

.Marz

April

Mai

Juni

Juli

August

Sept.

Okl.

Nov.

Dei.

- - --:

.Hu

IST

1 1

Fig. 28. — Relapsing Mania (7).

also by fairly long periods of excited or grumbling, irritated
mood.

The next group embraces manic forms. First we find in
Fig. 27 a " periodic mania." The duration of the attacks
fluctuates between three and nine months ; the intervals are
fairly irregular. The last attacks displayed a more raving

Alter

Jaauar

Febr.

Marz

April

Mai

JunI

Juli

August

Sept.

OkL

Not.

Dei.

L=;-^___

^11

Fig. 29. — Relapsing Mania with isolated periods of Depression (8).

mood. The seventh case (Fig. 28) had two attacks separated
by a pause of nineteen years, of which the second lasted
almost four years. Its outbreak was peceded by a very short
depression, as a first symptom of its place in manic-depressive
insanity. These relations become clearer in the eighth case

144

MANIC-DEPRESSIVE INSANITY

(Fig. 29) which otherwise presents a picture very similar to
the sixth case, only that here a depressive period on two
occasions immediately follows the manic attack. The ninth
case is very peculiar (Fig. 30). Here we see besides two

Allcr

Januar

febr.

Mill

Apiil

Mai

;uni

Joli

Aacust

Sept.

Oki.

Not.

DH.

— M

■ ^h

i— -

» ^

■a

h«

"»

■■

cdi

JPI

— 1

— ^

'Ml

~"JB

■

^^■^H

""fl

■

jf:

■^

-■-

-'^

-^^^i—

_• '..

W-

:i3-

Lf!<.

Fig. 30. — Periodic Mania with issue in Circular Insanit)' (9).

attacks of mania, somewhat longer, but running their course
with fluctuations, a large number of very short periods of
manic excitement, mostly with raving colouring of mood.
After the fiftieth year, as happened before about the thirtieth

Altet

Januir

Ftbr.

Mtrz

April

Mai

Juai

Juli

August

Sepl.

Okl.

No».

Dei.

TBI

/^ y.

/ / /

y y .'

■' / -•' '

/ /

.. / /

•• 'V

" / ^ 1

' / /

/ } I

/ /

' P

'/<-

■■

vV)<

//(

' ^

/ /

///

( ' ■

,■ ■

/ /

<' / ''

.- ..

^ y-

.■ ■

'' '' I^

' /''^

/ ■

•• / ^'

/^/^

.■ /

■ ■■ ^'

' / ,-■ '

■ y ■ -''

^ f /

/ ..'

, ■■ ^

hll

-•

/.- .■'

- / ■'

'/■

// ^

' , ■ . ' .-

■^ //.

V-

" ■-■/

' /. 'y

// /

■ ' /

.' / •

■ ,'

Vll

Fig. 31. — Chronic Mania (10).

year, the free intervals become always shorter, and there is at
last a regular alternation of manic and depressive periods
running a very short course, which lasts for years. Tlie con-j
elusion of this series may be furnished by a case of continuous^ j

FREQUENCY OF INDIVIDUAL FORMS 145

manic excitement (Fig. 31), which extends over more than
twenty-three years. The colouring of mood is often raving ;
at the commencement two short depressive periods were
interpolated.

Fig. 32. — -Folic a double forme (ii).

In the third group we first find a case with fairly regular
return of circular attacks similarly combined ; it would
nearly correspond to the " folie a double forme " of the French.

Alter

Januar

Febr.

Man

April

Mai

Juni

Jul!

August

Sept.

Okt.

Nov.

Dez.

:ms

■

Mil

._ ,

,■

■

,—

_-. „-

'til

A A

\ ?,7

,-. ^

,r..

-^ / /

,',•-■ -

■' //

,-- -

.Ml

■■

j^-g

'— "

■H

Fig. 33. — Folic circulaire (12).

States like the next case (Fig. 33) are much more frequent.
Here after a few attacks of manic excitement appearing in
irregular pauses, two combined attacks are developed, which

146

MANIC-DEPRESSIVE INSANITY

show repeated alternation of mania and depression inter-
rupted once by a short free interval. Between these two

AlKr

Janoar

Ftbr.

Marz

April

Mai

Juni

Juli

August

Sept.

Ok(.

Nov.

Dei.

;^ii

^^*

y-r-r-.

j^. , }jj.

-iP

^^^

—

imm-smx*;

'—'7-

j^yj

-' " " 1

1 11

1 1 1

Fig. 34. — Circular attacks with a long pause (13).

Alltr

Januar

Febr.

Marz

April

Mai

Juni

Juli

AuRusl

Sept.

Okl.

Nov.

Dti.

,111

'fll

^^_

"~~"~

^^^

^■"^^

-^Hi

■ .liB

ZJM

rr "

Fig. 35. — Circular Insanity with Depression in youth (14).

series of attacks, each of several years' duration, there is a
pause of nine years. These series themselves, except for

FREQUENCY OF INDIVIDUAL FORMS 147

certain irregularities, would correspond to the course of "folic
circulaire." We see something similar in the thirteenth case
(Fig. 34), but here the attacks are more simply combined ;
in contrast there are more mixed states than in the former
case. Moreover, here we observe only two groups of attacks

Alter

Januar

Febr.

Marz.

April

Mai

Juni

Juli

August

Sept.

Okt.

Nov.

Dez.

i-' ^'

hll

■ —

'".-

'/ll

Fig. 36. — Circular Insanity with prodromal delirious attacks (15).

separated by a pause of twenty-three years. Also in the
fourteenth case (Fig. 35) we have a free interval of twenty-
three years. But the first attack, beginning at the age of
twenty-six, is here a simple depression lasting three years.
Only at the return of the disease, at the age of fifty-two, does
its circular nature become clear. Manic and depressive

Alter

Januar

Febr.

Marz

April

Mai

Juni

Juli

August

Sept.

Okt.

Nov.

Dei.

X >

A :.'-, "

;-\ X ;

_/■■ 3

,<V.

/ /

•J

Fig. 37. — Depression with transition to Circular Insanity (16).

periods of very unequal duration now alternate for over six
years.

The fifteenth case (Fig. 36). which now follows, began at
the age of forty-seven in the form of a delirious state with
anxious excitement and hallucinations, which lasted a few
days, and which clinically could scarcely be interpreted.

148

MANIC-DEPRESSIVE INSANITY

That was followed eight years later by a second attack lasting
somewhat longer, then after two years by a third to which
was joined a state of simple depression with renewed mixed
state. Only at the age of sixty-one was the first pure mania
seen. From its recurrence, with gradual disappearance of the

Alter Janaar

Ftbr.

Marz

April

Mai

Juni

Juli

August

Srpl.

Okt.

Nov.

Dei.

fill

^^^^1

^^^H

^^^^^^^^H

^^^^^^^^^M

^^^H

^^^^^^^^H

TfT^^^BH

1 1 1 1 1 1 1 1 1

Fig. 38. — Depression of long duration with transition to Mania (17).

free intervals and interpolations of depression, circular in-
sanity was developed, which ran its course in short attacks of
changing colour. The course of the sixteenth case (Fig. 37)
presents, along with great deviations, yet in so far a certain
agreement, as after depressive attacks similar to begin with.

Alter

Jagaar

Febr.

Marz

April

Mai

Juai

Juli

Adgdst

Sept.

Okt.

Nov.

Drt.

2ii

^^^

' ■]

^HHV

■■

^■■1

^m m

^mm. ■

nmn

^^^^^^^^^H

ii\

"^^H

^^^

~"TH

^^^^

^^^^^

■■^^

It^

WK^^^^^^M

^—"■^■^■■■I^H

""^^^^^^^^^^H

i^H

^T^""

,r .

■m^^^^^

■■■

_!!!r3^H|BH

__^

MBi

p...

■■^■■l

imifi

■■^■■■11

i^Hi

■H(

T^^HI-EZ-r

/r^-^

"''' \

'/ ■'

^^1

[

'///

."in

■■1

^^^

Fig. 39. — Irregular Circular Insanity filling almost the whole life (18).

a markedly circular form appears in the sixth decade of life,
certainly with very long duration of the individual periods.
If one should here think first of the development of periodic
depression, that is more obvious in the seventeenth case (Fig.
38). At the age of sixty-five a depression of five and three-

FREQUENCY OF INDIVIDUAL FORMS 149

quarter years' duration appeared ; only then a state of
manic excitement followed. As the last (Fig. 39) I give a
case in which almost the whole life is taken up by a chain of
manic and depressive attacks. The malady began at the age
of twenty-one in manic form, and ran its course also the next
ten years essentially as periodic mania with short intervals
and occasional depressive interpolations. Then came a period
lasting nearly seven years of continuous manic or hypomanic
excitement intermixed with all kinds of mixed states and
short attacks of depression ; this was followed after a short
interval by a fairly irregular, uninterrupted alternation of
mania and depression.

If we give no more examples, that is not because
those already given represent adequately the multiplicity
of the courses taken by manic-depressive insanity ; it
is absolutely inexhaustible. The cases reported only show
that there can be no talk of even an approximate regularity
in the course, as has formerly been frequently assumed on the
ground of certain isolated observations. It is this experi-
ence which makes all delimitations and classifications futile,
which are grounded on definite varieties of the course.

In the intervals between the attacks the patients appear,
at least to begin with, perfectly well. Perhaps after a
depressive attack the particularly blooming appearance and
enjoyment of life are conspicuous, as after a mania the
dejection and the fretfulness, which the patient for a long
time cannot overcome. When the disease has lasted for
some time and the attacks have been frequently repeated,
the psychic changes usually become more distinct during the
intervals also. Even though striking morbid symptoms are
no longer demonstrable, yet a certain constraint and lack of
initiative, depressed, shy behaviour, slight lassitude, great
need of sleep and decrease of working capacity are often un-
mistakable. " In her good times she is still like a person who
has some trouble," was said of one patient. Other patients
on the contrary displa}^ irritability, very much exalted self-
consciousness, a quarrelsome disposition, unsteadiness,
agitation. A patient spoke of the times when she " had a
quite different character, displayed an exaggerated pride in
clothes, and had worldly leanings."

The patients often do not acquire clear insight into the
extent and the significance of their malady. They perhaps
admit that they were -excited or depressed, but lay the blame
for the most part on chance circumstances, their surroundings.

150 MANIC-DEPRESSIVE INSANITY

their being brought to the institution. They^xio not like,
therefore, to be reminded of the time when they were ill, evade
all discussion about it, and go out of the way of the physician,
if they chance to meet him later. A few patients, in whom
along with lack of insight, there exists still a certain excite-
ment, complain of the deprivation of freedom from which
they suffered during the attack and which they suppose was
illegal, or they compose descriptions of their experiences re-
presenting them in a half humorous, half enraged way, but
always with very personal colouring.

During the intervals very slight, merely indicated attacks
are extraordinarily frequent ; the morbid nature of these can
only be determined by more exact knowledge of the fully
developed phenomena, sudden vivacity, unusual enterprise,
the shaking off of daily cares, loquacity, merriment, irrita-
ability, or anxiety without foundation, introspective be-
haviour, inactivity and indifference continuing for weeks,
which then is traced back to overwork, some vexation or
something of the kind, but which disappears just as quickly
again as it came. One of my patients in a hypomanic attack
let himself be defrauded by a fashionable swindler ; the
moodiness, which then followed, was explained by the family
apparently quite naturally as due to the disappointment
undergone. In women fairly short attacks of excitement
readily occur in connection with the menses.

The patients themselves feel the approach of a fresh
attack sometimes days or even weeks beforehand, without
being able to account for it clearly to themselves. One of my
female patients frequently made an otherwise quite aimless
visit to the institution some time before the outbreak of the
attack ; she then showed no trace of morbid symptoms.
Others have still time before the excitement begins, to set
their house in order and then to go voluntarily for treatment.
A patient of that kind once jumped at midnight over tli«^ high
wall into the institution after a run of several hours.

The transition from one kind of attack to the other takes
place sometimes very suddenly and then invariably during
the night. The depressed patient wakes at the given time
contrary to his usual custom very early and is now manic.
A patient, who till then had been deeply depressed and
thought that he had caused an epidemic, appeared one mom-
morning with a red carnation in his button-hole. Another,
who was afraid of softening of the brain, appeared to him-
self " as transformed," A dispirited and dejected patient

FREQUENCY OF INDIVIDUAL FORMS 151

declared abruptly that happiness had come over her. The
excited patient feels himself one morning tired, done out,
inhibited ; he had been " too merry, too frivolous ; now it
overtakes him."

More frequently one sees the change of states being pre-
pared for a long time beforehand. The expression of
countenance and the bearing of the patient, up till then
depressed, becomes gradually freer, his eye more animated ;
appetite and nourishment improve. " I take heart rather
than despair," said a female patient. Another reported an
attempt at suicide in the words, " The cord broke, thank
God." And a patient, who had asserted that his lungs were
wholly eaten away, declared, " They're growing again."
The skin regains its former freshness, the bearing its
elasticity. Gradually the patient becomes more accessible,
shows more interest in his surroundings, begins to employ
himself more continuously, feels himself easier and in better
health, gives utterance to the longing for freedom and his
own work, " for spring and the budding trees," looks forward
to his discharge, and often for a considerable time makes the
impression of a convalescent. A discharged patient wrote,
when she was in this state, that she wished to come in as a
nurse, " but only in the quiet wards."

A patient gave us the following information about his
state : —

" The weariness also already abates somewhat, and walking is no longer
so difficult for me, but a troublesome heaviness is still always in all my
limbs and still drags my body like lead down on to the chair or to bed. Yet
I think that the Almighty is again strengthening me by his power and is
supporting me, and therefore I am now happier again, I praise and adore
him, the All-bountiful, who helped me so wonderfully by your hand. The
time of my life " of the soul " dawns for me like midday, and the darkness
has become the bright morning for me ; my soul lives, hopes, and rests
again in the triune God, our Lord."

The morbid nature of the apparent improvement is often
now already indicated. " I feel myself unnaturally well," a
patient declared to me, who later ended in suicide ; she felt
herself younger by years, slept a very short time, and was
yet always fresh ; " It can't really go on like that." Isolated
actions already perhaps have a manic touch, while in general
the symptoms of inhibition still predominate. I treated a
female patient, who, after severe depression in spite of complete
sense, was scarcely capable of bringing forth a word, but, at
the same time, was very well physically, often smiled, and, to
the astonishment of everyone, suddenly administered a box

152 MANIC-DEPRESSIVE INSANITY

on the ear as quick as lightning. A lady, who was still
troubled by tormenting ideas of persecution, unexpectedly
seized hold of a peasant-woman in order to dance round the
table with her. Another, as she despairingly went past a
draper's shop, had a sudden fancy to buy herself a ball dress,
and to the extreme surprise of her rjslatives appeared in it
two days later at a ball, which she had already declined.
More and more then the exalted mood gains the upper hand.
" To-day is Good Friday, but in me it is already Easter,"
wrote a patient in her diary.

The dawning of more pleasant pictures is painted very
characteristically in the following letter of a patient, from
whom I have reproduced above a description by herself of her
hypochondriacal sensations. When writing this letter to her
mother the patient still suffered from severe depression in
spite of considerable improvement ; she died soon afterwards
by suicide.

" How I long so terribly for you and for life, and yet I feel that I must
die. And I love you and my brothers and sisters more than life — than rich,
beautiful, pure life, which I should like so much to share with you, as I
should — and instead of this I cause you such grief. O do not curse me, I
am indeed ill and not worthy to be with you ; forgive me what I have
already said to you. — And to-day I am so comfortable, that I feel that I
shall now fall asleep, and everything, everything, that is so wonderfully
beautiful in life, appears now so rich and bright before me, — your love and
the work — and the garden and the flowers and the forest. And of the
linden court, just as it was, when your work and your vigorous hand and
your beauty-loving eye decorated it, it appears to me now in such vivid
dreams as never before. And do you still remember, how wonderfully
beautiful the summer evenings on the verandah were ; where the two tall,
slender fir-trees stood in the clear evening sky, and the wild vine stretched
as a transparent curtain from the washing-house over to the one fir-tree
and from there to the other, and sometimes the wind moved it gently. And
the clear, bright moon looked through between the fir-trees. And we sat
round you on the verandah and near by the waterfall of the mill-wheel
murmured. And when in the evening the rat took a walk on the wire from
the granary to the water trough and we watched it and at first did not know
what kind of night-reveller it was, that was so mysteriously interesting too,
and when Fritz then with a sure aim shot it, that was then vigorous reality.
And very specially beautiful it was when the roses and lilies bloomed and
the glow worms shone, and then behind the garden the fragrant meadow
and at the edge of it our little wood, where we played our games as children,
in which Fritz was always the terrible robber-knight ! And when the bees
buzzed so in the chestnut-trees decorated with candles — that was too beauti-
ful for sitting underneath and dreaming . . ."

The mixture of hopelessness with sentimental exuber-
ance should be noticed, also the wordy rev.elling in poetic
memory-pictures slightly suggestive of flight of ideas, the
constant fresh connection with " and " a sign that ever fresh
pictures were crowding in.

FREQUENCY OF INDIVIDUAL FORMS 153

In a similar manner the opposite change takes place.
The body weight, which had latterly increased in spite of the
excitement, begins to fall slowly again. Now the great over-
busyness gradually slackens ; the big plans go into the back-
ground ; the patient has " no longer any of that spirit,"
" would Hke to rest." " The capacity for thinking ceases ;
before now there was a hurrying of work," declared a patient.
Mood becomes quieter, more serious, more gloomy. A young
lawyer, who in excitement had composed a prize essay, had
not the courage in the following depression to give it in.
Fortunately the excitement returned in time, and he won the
prize. Now and then there are isolated remarks about dis-
appointed hopes, attempts that have failed, hard experiences ;
movements become slower, more relaxed, feebler ; the ex-
pression becomes dull, exhausted, the appearance tired, and
now all the remaining phenomena of the former depression
reappear one after the other.

For the clearer elucidation of all these extremely remark-
able psychic states I reproduce a fragment from the compre-
hensive description of himself by a tailor, whose father
came to his end by suicide, while he himself experienced
the first attacks of moodiness in his fourteenth year,
which were repeated several times, but never lasted more than
a few weeks. He then got the feeling that he suffered from a
" congenital disease."

" My elder brother often said to me, ' You're sitting there as if in a
dream.' He was right too, for my disease is so very Hke a troubled dream
in the waking state. Already when I was a boy of fourteen, I found life
unbearable in this state, and I had at that time already thoughts of suicide.
I was so lively before and afterwards, then so sad, that my relatives were
struck by it. I was always asked, ' What's the matter then ? ' 'In head
and in heart,' I always said, for how I feel then cannot be described or told.
I knew then even at the first appearance of this evil, that it was mental
disorder, for I could retain nothing, was clumsy in everything, had no
pleasure in anything, not even in money ; finally I was laughed at because
I did as if I were going to die immediately. Each time I feel as if I could
not survive these attacks. I was envious of other people when they were
merry. I always kept away from any amusement, and if I had to go now
and then with my companions, I sat there as a dumb person, for I couldn't
manage to speak, or only disconnectedly as a stutterer. In this state I
have never yet quarrelled with any one. I was considered sensible and
docile every time, for then I have neither will nor sense, I am a veritable
automaton. As hot-tempered as I am otherwise, just as cold am I in
the disease. Every time a change has taken place in me as if I were a
quite different person from other times, and I am convinced that it is so.
"The past sweeps through my head ; every mistake, which I have made in
a normal state, oppresses me. When ill I could not tell a lie . . . At the
beginning I was making coats, then as the disease gradually became more
severe, I had to change to waistcoats ... I was again a bungler, no
longer a tailor . . . Then (at the age of twenty-four after many depressive
attacks) I felt a peculiar condition come over me, but not depressed and

K *

154

MANIC-DEPRESSIVE INSANITY

without thought, but the opposite. I was merry, overstrained ; in spite of
drinking a great deal of wine at any time, I was still not drunk, for in this
excitement no drink whatever could do me any harm ; in contrast to this I
can stand little in my normal state. Whether I drank little or much, I
remained the same, and when I drank far more than usual, I never had head-
ache or sickness the next day. I did not care at all for money in this
excited state, for I considered myself as count, actor, poet, and so on . . .
After a few weeks my brother took me to the hospital, for I did stupid
things, went into hotels without money, and so on. Work then is certainly
child's play to me, but my head was veritably glowing with heat, if I sat
for some hours. I was put in a cell for raving mania, a kind of pig-sty, and
was there for three weeks ; already I had lost my memory for a fortnight,
then I was put in the hospital, where I remained about four weeks. I had
smashed everything there, also torn to pieces . . . Shortly before my
marriage this mysterious disease stole upon me again. I was described
everywhere as a quiet, respectable man ; of course I could not talk much.
I had a sad woddint;, and I believe that no other man has ever appeared

before the altar in such moodi-
ness. Formerly I gave instruc-
tion in cutting out, and when I
was ill I could scarcely make the
simplest suit. The bad memory
which I have in the present dull
state. I am very bad at remem-
bering names. I may be told a
simple name ; next minute I
have forgotten it. I often wish
that I were a very stupid farm-
servant, but only in my present
state. It is indeed a singular
wish, but anyway a peasant
troubles little about where the
grass or the grain comes from.
When I am ill, these things
always occur to me ; I should
like to get to the bottom of
everything without wishing it.
I just have no will ; I cannot
take anything in hand, nor can
I carry out anything ... In the
pwiii.uiict. excited state I am more than
other people ; I can talk nine-
teen to the dozen. Everything is easy to me ; in short I am easy-going ;
then life too is easy to me ; I don't think of to-morrow."

The following verse characterizes, perhaps, still more
distinctly the contrast of the states ; it was composed by a
patient in the transition period from severe depression to
mania, just when the first indications of re-awaking enter-
prise stirred in him : —

" Krank ist der Sinn, wcnn er ini schwarzcn Jammertal
Ringsum gehaufter Leichen seiner bangen Sorgcn,
Ach ! auch das liebend Herz den Seincn selbst verborgen, —
Ein lecres Geisteswrack der dcprcssiven Qual.
Prunkstrahlend andrerseits, nicht fragcnd wo und wie,
Entfesselt irdschen Seins, erhebt er seine Schwingen,
Lustschwelgend, jubelnd in den Himmel einzudringen :

Ihm spendete ein Gott imsterbliches Genie !

Nein, ach ! — er steigt und fallt im Wahne der Manie I "

Fig. 40.- ii

FREQUENCY OF INDIVIDUAL FORMS 155

The orthodox course of the gradual transition from one
state to the other is often extremely striking. The thorough-
going contrast of the states usually extends to the smallest
details of the conduct of life, clothing, hair-dressing, to all
likes and dislikes, so that one might think there were two
perfectly different people. This contrast appears very dis-

m^^^

^Sl

^^^^^^^^^^^^^^B''^ ^^^^1

BU^' j^^

Wf^L^gES!^^^

,>x

W^^"^ ^

I^^S^

I^&IihS^^'

1^.

"4
1

Fig. 41 .- Mani;!.

tinctly in a comparison of the illustrations. Fig. 17 (p. 80)
and Fig. 40, also Fig. 18 (p. 81) and Fig. 41. The first two
show the same patient once in stupor with profound clouding
of consciousness, then a few weeks later in slight hypomania
with a rather affected smile and wearing an enormous bunch
of flowers. The other two pictures represent the same patient
in mania and in a severe depressive stupor which followed
closely, the one time with cheerful appearance ready for

156 MANIC-DEPRESSIVE INSANITY

enterprise, a flower in his buttonhole, a cane in his hand, and
smoking two cigars at the same time, the other time in bed,
with rigid features straining anxiously. The specimens of
writing 3 and 4 likewise show well the change of states. The
first with the careless, disconnected, very much shortened
stroke was written in excitement after a disputewith the nurse;

yyi^A^^ >^' '^^ ^^^^

Specimen of Writing 3. Manic-depressive Insanity ; Excitement after
a dispute with a nurse. (13. ii. 92, 2 p.m.)

Specimen of Writing 4. Depression. (14. ii. 92, 8 a.m .)

whereas the second, which in the small, cramped, very sloping
writing indicates the depression that has set in, was written
on the morning of the next day. The difference in tone and
contents of the notes is also extremely characteristic.

Ascaffenburg made association experiments with the
patient portrayed here. In the percentage of clang

FREQUENCY OF INDIVIDUAL FORMS 157

associations they furnished a clear picture of the gradual
disappearance of manic excitement and the transition to
the state of depression. They are reproduced in Fig. 42 ;

M I

YE YUL

YO.

9«t 95

95 95

Fig. 42. — Comparison of percentages of clang associations in Mania and
Depression.

the segments of the abscissa axis correspond each to a
month. With the disappearance of manic excitement,
which at the beginning of the experiment had already lasted
more than a year in the most severe form, the number of
clang associations falls quite regularly, and completely
returns to normal shortly before the
discharge of the patient, which took
place in December 1895. About the
end of the same month an unusually
profound depression with extremely
severe inhibition set in, which made
association experiments impossible. The
two next experiments in April 1896
furnished not a single clang association,
the one in July gave one per cent.
We were able to follow the transition
from depression to mania, as Fig. 43
shows, by means of perception experi-
ments with the aid of the pendulum
tachistoscope. It is seen here how in
the course of about a month the num-
ber of correct perceptions, already small
at the beginning, decreases steadily while
at the same time the number of in-

Date of Experiment :

19. VII. 5. VIII. 21. VIII.

to 3. Vl'I. ig. VIII. 23. VIII.

0.82 0.48 0.22

2.74 2.96 3.75

Fig. 43. — Number of
right andwrong^ercep-
tions in the transition
from Depression to
Mania.

Correct perceptions.
Mistakes.

158

MANIC-DEPRESSIVE INSANITY

correct perceptions increases in far greater measure. At
the same time also the patient, who at first was still
distinctly depressed, had become definitely manic.

The course of the body-weight in two double attacks of a
female patient with slight hypomania and simple inhibition

>».

tto

-J

u A

'^^

Tfn

rsf

110

Hypomania | Depression | Hypomania | Depression |

Fig. 44. — Manic-depressive Insanity ; two double attacks.

is shown in the curve Fig. 44. We see how it increases during
excitement and again falls accurately with the commence-
ment of depression. Also in the different behaviour of the
pulse curve the contrast of the two morbid periods is marked
with surprising distinctness.

CHAPTER IX.

PROGNOSIS.

The prognosis of manic-depressive insanity is favourable for
the individual attack. For long the prospect of recovery
especially in manic excitement has been considered very
good ; with this the circumstance may be connected that
mania is preferably a disease of youth. In fact one may,
even after very long duration of excitement or depression
with reliable diagnosis, still hope with great probability for
complete restoration to health. In especial one must not let
oneself be deceived by the mental inertia which apparently
exists often during mania or after severe raving, and which
is usually only the expression of inhibition of thought and
later, as a rule, completely disappears, although slowly.

On the other hand in every case which belongs to manic-
depressive insanity we must reckon with the possibility that
the disease will be repeated several times or even very fre-
quently. How great this probability is, cannot at present be
stated with certainty. The following up of a large number of
cases throughout life could alone settle the point. As those
who have only been ill once, frequently avoid further observa-
tion, while those with frequent relapses represent a very con-
spicuous part of institutional Hfe, it may readily be thought
that in general we are inclined to over-estimate the danger
of a return of the malady. If we only were able to decide
with greater certainty whether the isolated case belonged to
manic-depressive insanity or not, it might turn out that in a
not altogether inconsiderable number of cases there was only
one attack, or, as one may also perhaps express it, having
regard to the pauses extending over thirty years or more,
that the patients died without a relapse taking place. In any
case it must be taken into account that the length of the
intervals in almost 20 per cent, of the cases amounts to ten
years and over.

As appears from our former comparison, the cases running
their course in the two forms show the greatest tendency to
frequent repetition. The commencement of the malady with

i6o MANIC-DEPRESSIVE INSANITY

a double attack will, therefore, make the prospects for the
future appear more unfavourable. A series of attacks
following one another without interruption and changing
repeatedly in colouring must be regarded as specially critical.
It often signifies the development of permanent circular
fluctuations of state, as in our examples 9, 14, 15, 16, 18.
But the morbid process may also, as examples 12 and 13
show, again come to a standstill, and there may be pauses of
many years. In the years of involution one must be pre-
pared for the return of former attacks ; often just at this
time there is a considerable series of attacks similarly or
variously coloured, as in our cases 2, 3, 9, 14, 16. The time
of the return, if a certain regularity has not already appeared,
cannot up till now be even approximately foretold. In
general frequent return of the attacks with short pauses may
. be certainly reckoned on in the cases beginning very early
and without external cause. If the malady, however, first
appears later and in conjunction with far-reaching injuries,
perhaps in confinement, relapses do not usually follow so
quickly.

How far the clinical peculiarities of an attack to some ex-
tent allow reliable conclusions to be made as to the further
form of the morbid state, is up to now still quite obscure.
Perhaps, however, with very extended observation some
prognostic rules may be got, although the incalculable in-
fluences of personal predisposition and conduct of life will
always be important sources of error. In the meantime one
may, perhaps, say that hypomania is most frequently con-
nected with simple inhibition, while severe acute mania is
generally followed by strongly marked depression with
delusions and a tendency to stuporous states. Clouding of
consciousness, hallucinations, and delusions seem, when they
appear, readily to accompany both phases of the disease.

Even when manic-depressive insanity lasts a very long
time, the psychic state of the patients in the intervals does
not usually suffer any considerable injury, if the attacks
themselves run a mild course. On the contrary there are
many of those patients who in the free intervals do very good,
indeed distinguished mental work. Kahlbaum has compared
these slighter forms of the disease as " cyclothymia " ' with

* Hoche, Uber die leichteren Formen des periodischen Irreseins, 1897 ;
Wilmanns, Die leichten Faile des manisch-depressiven Irreseins und ihre
Beziehungen zu St6rungen der Verdauungsorgane, 1906 ; Romheld,
Sommers Klinik, ii. 449 ; jellifle, American Journal of Insanity, 67, 661.

PROGNOSIS i6i

the more severe forms leading to weakmindedness, which' he
called " vesania typica circularis." This distinction has,
however, only a limited practical value, in so far as the
c37clothymics cannot in the ordinary sense be regarded as
" suffering from mental disorder," and, therefore, are liable
to an essentially different judgment and treatment. But
fundamentally it obviously concerns everywhere the same
morbid processes. That is made evident not only by the
lack of all sharp boundaries between cyclothymia and manic-
depressive insanity, but also by the circumstance, that we
often enough can observe in the same morbid course along
with severe attacks of depression or acute mania numerous
sUght cyclothymic fluctuations of mood also.

Violent and long-lasting attacks of manic-depressive in-
sanity may likewise end with complete restoration of the
former psychic personality, if they only occur once in a life-
time. On the other hand with increase of attacks, in certain
circumstances perhaps also with very severe single attacks
extending over many years and in advanced age, there exists
the greater or less danger of the development of a psychic
decline. Perhaps in the other direction we must make the
development of lasting changes responsible for the unfavour-
able course of the disease. The states of weakness, which
appear in such cases, invariably let the after-effects of past
attacks be recognized. Many patients remain permanently
quiet, depressed, uninterested, stand about in corners with
dejected or anxious appearance, fold their hands, lament in
a low voice, when questioned give hesitating, monosyllabic,
but sensible and usually appropriate answers. They are
inactive, irresolute, timid; have to be forced to everything,
resist energetically when much interfered with. Frequently
also the residua of depressive delusions still persist ; the
patients call themselves the devil, ask for forgiveness, for a
mild punishment, are afraid that they will be sent away, that
they will have to remain there for ever.

The antithesis of this group, which might be called
" chronic melanchoha," is made up of those patients, which
Schott 1 has brought together under the name of " chronic
mania." Here manic features dominate the picture. The
patients are in general sensible and reasonable, and perceive
fairly well ; memory and retention are also fairly well pre-
served. On the other hand there exist increased distracti-
bility, wandering and desultoriness of thought, a tendency to

^ Schott, Monatschr. f. Psychiatrie, 1904, i.

i62 MANIC-DEPRESSIVE INSANITY

silly plays on words, poverty of thought. The patients
have no understanding of their state, consider themselves
perfectly well and capable of work.

Mood is exalted, but no longer exultant, enjoying activity,
but silly and boastful ; occasionally it comes to flaring up
without strength or durability. The finer emotions are con-
siderably injured. The patients show httle interest in their
relatives, do not shrink from making coarse jokes about them,
do not trouble themselves about their affairs, do not worry at
all about their position and their future, at most once in a
way they beg without energy for discharge. Only the coarser
enjoyments, eating, drinking, smoking, snuffing, still aro\ise
in them vivid feelings, further the satisfaction of their
personal wishes and wants ; everything else has become to
them more or less indifferent. At the same time the patients
develop an activity often very disturbing, without, however,
more serious restlessness. They like to interfere in every-
thing, act as guardians to the feebler patients, snarl at them,
take from them what they want. They collect all possible
rubbish in their pockets, make a mess with it all round about,
rub and wipe things, adorn themselves with rags and scraps
of ribbon, talk more than their share, swagger, try to gain for
themselves all possible little advantages. They can mean-
time scarcely, or not at all, be employed for profitable work
on account of their unsteadiness and indifference as well as
their inclination to all sorts of mischief. Schott is of the
opinion that severe hereditary taint specially favours this
issue ; also the residence in an institution continuing often
for decades with its blunting and narrowing influences, as well
as approaching age, might have a certain influence. In spite
of their smaller share in general in manic-depressive insanity
men are said to suffer somewhat more frequently from this
decline.

At this point we have to mention in a few words another
group of cases, in which the psychic decline reveals itself in
continual, abrupt fluctuation between lachrymose anxiety,
irritability, and childish merriment. States of this kind
sometimes appear to be developed from a continuous
accumulation of short circular attacks. The original de-
limitation of individual attacks becomes more and more
obliterated, so that it finally becomes impossible to
characterize the state at any given moment. A kindly
word suffices to make the patient sitting in apparent distress
smile pleasantly, clap his hands, sing, dance about, but just

PROGNOSIS 163

as quickly do tears, self-accusations, or silent brooding again
follow, which then perhaps gives place to a jocular outburst
of abuse, all without any deep-seated feeling, desultorly
changing and easily influenced. Left to themselves the
patients appear for the most part indifferent, without desire,
poor in thought, they display no specially striking colouring
of mood ; they are able to employ themselves diligently.

Finally, the question would still have to be raised, whether
in certain circumstances some of the mixed states might not
also issue in a peculiarly coloured decline. To myself that
appears probable for depressive excitement. But it would
be conceivable, that for example manic stupor also or de-
pressive mania might once in a while take such a course.
Occasionally, I have come across cases, which seemed to
suggest such an interpretation, but further investigation in
the field of observation furnished by large institutions are
necessary before it will be possible to form a definite opinion
about this question.

The prognosis of manic-depressive insanity is to a certain
extent made uncertain by its relations to arteriosclerosis. I
have already directed attention to the fact that the disease
by no means rarely develops first in the years of involution
and even in still more advanced age, sometimes just after
an apoplectic seizure. On the other hand numerous ex-
periences are forthcoming which give evidence for the pre-
mature appearance of arteriosclerotic changes in our patients.
Albrecht reports that in fifty-four cases he could demonstrate
arteriosclerosis eighteen times, and of these more than the
half were between fifty and sixty years of age, six were
almost fifty. What view should be taken of this connection
remains for the present obscure. It might be possible that
the frequent and great fluctuations of the blood pressure and
of the vascular innervation, which appear in the disease,
signify injury to the vessels. If one prefers the assumption
of chemical causes, one might think that the same poison,
which engenders the alternation of psychic states, affects
also the arterial walls, just as one thinks of the relation
between syphilitic, that is paralytic, vascular change and
the corresponding cortical diseases ; thus the appearance of
circular attacks, when arteriosclerosis already exists, is more
readily comprehensible. For this view epileptic attacks
also might not be without significance ; they occur, indeed,
seldom, but now and then they are observed. I saw a
patient, fifty-two years of age, who did not suffer either from

i64 MANIC-DEPRESSIVE INSANITY

alcoholism or syphilis, suddenly collapse with apoplexy after
repeated, severe epileptic attacks in the fifteenth year of a
manic-depressive insanity. Only in the last weeks of his life
did the symptoms of arteriosclerosis appear distinctly. His
mother also had died of apoplexy.

When in the course of manic-depressive insanity arterio-
sclerotic changes are added or, what also occasionally
happens, fairly severe senile changes, psychic states of weak-
ness may be developed, which obliterate the original morbid
picture. I have repeatedly seen patients, who had suffered
from a series of attacks without any injury to their psychic
capacities worth mentioning, become demented in advanced
age and indeed in the well-known form of arteriosclerotic
or senile weakmindedness. As we know cases enough of the
opposite kind, in which manic-depressive patients suffer no
kind of psychic loss at all in spite of advanced age, we must
possibly always connect the appearance of a definite dementia
of that kind with the addition of a fresh, more or less, in-
dependent disease. Pilcz is of the opinion, that the develop-
ment of dementia is essentially related to the existence of old
brain scars. That would probably only happen so far as
these are the expression of a morbid process, which is still
capable of progression, as syphilis or arteriosclerosis.

Issue in death is not very common in manic-depressive
insanity. It may be caused by other diseases of various
kinds, by simple exhaustion with heart failure (collapse) in
long continuing, violent excitement with disturbance of sleep
and insufficient nourishment, by injuries with subsequent
blood-poisoning, and by fat emboli in the lungs in con-
sequence of extended bruising or suppuration of the sub-
cutaneous connective tissue. Very stout people with in-
sufficient functional capacity of the heart muscle are de-
cidedly endangered in severe manic attacks. Finally outside
of institutions suicide also claims a considerable number
of victims, especially in the sUght cases apparently not yet
or no longer in need of institutional treatment. With suit-
able shelter and supervision this serious danger can be very
much restricted, but unfortunately not always excluded
with absolute certainty ; in particular, premature discharges
now and again lead to bitter experiences. In elderly
people apoplectic attacks occasionally occur. As yet there
is nothing certain to report in the morbid anatomy.

CHAPTER X.

CAUSES.

Manic-depressive insanity in the sense here deUmited is a
very frequent disease. About lo to 15 per cent, of the
admissions in our hospital belong to it. The causes of the
malady we must seek, as it appears, essentially in morbid
predisposition.

Hereditary Taint ^ I could demonstrate in about 80 per
cent, of the cases observed in Heidelberg. Walker found it
in 73.4 per cent., Saiz in 84.7, Weygandt in 90, Albrecht in
80.6 per cent., and in the forms with numerous attacks still
somewhat more frequently. Taint from the side of the parents
he found in 36 per cent, of the cases, in the last-named forms
in 45 per cent. The values got in Munich are considerably
lower on account of the much less complete knowledge of the
previous history. But still mental disease or alcoholism could
be demonstrated in the parents in one-third of the cases, the
latter alone in something over 10 per cent, of the cases. Here,
as in Heidelberg, I had the experience that cases of manic-
depressive insanity in parents or brothers and sisters were
disproportionately frequent. Further, I very often found
suicide, which points in the same direction. Lastly, the
occurrence of psychopathic personalities in the family was
also frequently reported, of whom likewise so many have
certainly to be reckoned to the domain of the malady dis-
cussed here. On the other hand, epilepsy, arteriosclerosis,
and, as far as an opinion could be formed, dementia prsecox
also do not seem to play any part worth mentioning in the
hereditary series. Vogt reports that in 22.2 per cent, of his
cases mental disease existed in the father or the mother, in
35.2 per cent, in the brothers and sisters, against the corre-
sponding values of 12.2 and 15.3 per cent, in other forms of
insanity. Kolpin has communicated a very instructive
pedigree, which is reproduced on the following page.

It is seen that of ten children of the same parents, who
probably were both manic-depressive by predisposition, no

^ Fitschen, Monatsschr. f. Psychiatrie, vii. 127.

i66

MANIC-DEPRESSIVE INSANITY

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CAUSES 167

fewer than seven fell ill in the same way ; of the five descend-
ants of the second generation four have already fallen ill.
Rehm has instituted investigations about the children of
manic-depressive parents. He found among forty-four
children from nineteen families signs of psychic degeneration
in 52 per cent., particularly in 29 per cent, abnormal
emotional predisposition, by preference in the depressive
sense. Bergamasco established that among 157 patients
from fifty-nine families 109 belonged to manic-depressive
insanity ; the remainder were divided among pellagrous
insanity, dementia praecox, senile dementia, epilepsy,
paralysis, hysteria.

Evidence for the assumption of inherited syphilis was
present in only a few cases. The endowment of our patients
was in 62.2 per cent, of the cases, in which information was
to hand, said to be good or very good. There were 13 per
cent, who had been good scholars, 10.7 per cent. poor.
Therefore, although among the patients there were a few
who might be considered weakminded, still in general their
intelligence seemed to be rather above the average. That
artistic predisposition is relatively frequent, was repeatedly
indicated ; here relations probably exist with the liveliness
and mobility of the emotions. Symptoms of physical de-
generation, especially malformations, distortions, smallness
or hydrocephalic bulging of the cranium, infantilism, are
often present ; of many patients it was reported that they
had suffered from infantile convulsions, and for long from
nocturnal enuresis, and had learned late to walk or to speak.

Age. — 'The distribution of the first attacks of the malady
with regard to age are shown in the diagram (Fig. 45). In
rare cases the first beginnings can be traced back even to
before the tenth year. Friedmann ^ describes in young
persons manic or depressive attacks, which run a mild course,
and which are often incited by external causes, or series of
such ; he calls these " mild forms." Stuporous, delirious,
and somnambuUstic states are frequent in these ; some-
times complete and lasting cure is said to take place, which
indeed could only be established with some certainty after
decades. Liebers has described a case of mania lasting six
months in a boy under five years of age.

The greatest frequency of first attacks falls, however, in
the period of development with its increased emotional ex-
citability between the fifteenth and the twentieth year. But

^ Friedmann, Monatsschr. f. Psychiatric, xxvi. 36,

i68

MANIC-DEPRESSIVE INSANITY

in the next decade also the number of attacks is still very
great, and only gradually decreases after the thirtieth year.
This fall is interrupted between the forty-fifth and fiftieth
year by a fresh rise, whose after-effect is seen in the slower
descent of the numbers up to the fifty-fifth year. Obviously
the influences of the years of involution here play a part.
Isolated attacks begin first in very advanced age. Petren
observed a case which began at the age of eighty and at
eighty-eight still presented no symptoms of senile dementia.

ll.

Years 10 16 20 26 30 35 40 45 6<) 56 -60 66 70 85
0.4 2.6 16.4 16.816.412.7 9.3 7.0 7.8 6.0 3.9 2.1 1.1 0.1

Fig. 45. — Distribution of the first attacks of Manic-deprc.ssivf insanity
(903 cases) with regard to age.

A further view of the significance of age is afforded by
Fig. 46. Here the distribution of the cases beginning at the
different ages is given according to their cHnical colouring.
Purely manic and depressive cases were kept distinct and
also those cases in which manic and depressive morbid
phenomena were conjoined or were fused to well-marked
mixed states. Only states fully developed one way or the
other or mixed were taken into account, but not the ad-
mixture of isolated transitory morbid symptoms of opposite
kind in an otherwise unequivocal clinical picture. From
these considerations the noteworthy fact emerges, that the

CAUSES

169

colouring of the clinical pictures is influenced by age in a very
decided manner. The cases running a purely manic course
begin with marked preference in youth, before the twenty-fifth
year. If the observations, of which there is certainly only
a small number, do not deceive, it seems that with the
commencement of the years of involution the tendency to
manic attacks once more increases and then rapidly and to
a considerable extent decreases. Cases running a purely
manic course, which begin after the fifty-fifth year, are quite
the exception. The frequency of cases, in the narrow sense
manic-depressive, also distinctly decreases with advancing
age, although with small fluctuations, an experience which
it would not be difficult to bring into accord with the slighter
.tendency of advanced age to manic attacks. On the other

I I Manic
E^ Mixed

►Attacks

Melancholic I

Years 15 20 25 30 X

M. 23.9 25.7 2;i.9 13.0 17.4 14.3 22.2 7.2 5.6 2.9 3,3

M. + D. 51 8 50.7 40.6 38.1 32.2 30.9 25.4 18.5 2.5.9 22.8 16.7

U. 25.9 23.6 3S.5 48.9 .50.4 54.8 .52.4 74.3 68.5 74.3 80.0

Fig. 46. — Colouring of the attacks at the dififerent ages.

hand, depressive attacks show an almost contimious increase
from the twentieth to the seventieth year and finally reach
the height of 80 per cent, of all cases.

The fact, that states of depression are specially frequent
at the more advanced ages, had already before this forced the
supposition on me, that the processes of involution in the
body are suited to engender mournful or anxious moodiness ;
it was one of the reasons which caused me to make a special
clinical place for a portion of these forms under the name of
melancholia. After the purely clinical foundations of this view
were shaken by the investigations of Dreyfus, our representa-
tion also now lets the causal significance of age appear in a
light somewhat different from my former view. It is
certainly incontrovertible that after the forty-fifth year,

170 MANIC-DEPRESSIVE INSANITY

thus with the beginning of the dimacteric in the female sex,
which principally controls the numbers, a great increase of
depression begins. On the other hand, consideration of the
whole diagram makes it probable that it here only concerns
the increase of a change in the clinical behaviour of the
morbid attacks which had been coming on long before.
The increase of depression is already so pronounced in the
third and fourth decade and relatively progresses with such
regularity, that a separation of the years of involution from
the previous periods of life cannot be carried out from this
point of view.

We are, therefore, forced to the conclusion that the in-
crease of depression is not caused by the special circumstances
of the years of involution, although it seems to be favoured
by them, but that it in general stands in a certain relation to
the development of the psychic personality. We have here to
remember the fact, that the suicidal tendency of mankind
also experiences a progessive increase in the course of life,
and that children possess the ability to make good again the
influence of emotional injuries in far higher degree than older
people. The tendency to elaborate the incitements of life
and probably also morbid disorders in the sense of depressive
states, appears accordingly to increase with the maturing and
the final torpidity of the psychic personality, it may be that
with the gradual loss of pliant adaptability to the circum-
stances of life, the internal and external struggles become
harder, or it may be that in the more richly developed
consciousness the reverberation of mournful moods is less
easily obUterated, or lastly it may be that with the greater
demands of the struggle for existence the wounds which
it causes become deeper.

At this point the experience which I had of the form of
manic-depressive insanity among the natives of Java, is
perhaps not without significance. There was a whole series
of cases there which I thought I should include in this form ;
these were relatively not fewer than among the European
patients examined at the same time. On the other hand the
clinical pictures diverged in so far from our observations,
that almost exclusively states of excitement, and often con-
fusion, were concerned. Well-marked states of depression
lasting for some time, such as fill the observation wards at
home, I could not find at all ; they are thus in any case rare.
To this corresponds the absence of ideas of sin and of suicidal
tendency. These observations confirm the view, that for

CAUSES 171

the form of the clinical picture, which our morbid process
produces, the idiosyncrasy of the psychic personaHty in
question is of great importance. A comparison might be
made between the behaviour of the Javanese patients and
that of our youthful patients, a psychically undeveloped
population with the immature European youth. We might
bring forward similar considerations with regard to the states
in dementia prsecox, and we shall later have to come back
to them again in the discussion of hysterical disorders. The
circumstance is also noteworthy, that the frequency of manic-
depressive insanity appears to be different in different races.
Reiss specially emphasizes the occurrence of numerous states
of depression among the Suabians.

The distribution of a considerable number of single cases
of manic-depressive insanity in regard to age will also give us
information about the part which age plays in the form of the
malady. I give here the percentage distribution of 1704
attacks in periods of five years. Unfortunately many cases
with very numerous attacks could not here be taken into
account, because the time of their appearance could not be
accurately ascertained : —

Years .
Per cent.

— 10
0.2

—15
1.4

— 20
II. 2

—25
12.3

—30
15.2

—35
12.5

Years .
Per cent.

—40
II. 6

—45
8.0

—50
9.1

—55
7-3

60
5.0

-65
3.8

Years .
Per cent.

—70
1.8

—75
0.3

O.I

-85
0.2

Here it is seen that the greatest frequency of the attacks
naturally falls later than that of the first attacks, about a
decade. It can further be seen that between the forty-fifth
and the fiftieth year also an increase of cases takes place. As
it is relatively greater than the increase recorded above of the
first attacks, we may conclude that the return of the attacks
in the time mentioned is also facihtated ; otherwise the differ-
ence on account of the considerably increased number of
observations would rather have been obliterated.

The following summary gives particulars about the dis-
tribution of single attacks according to their colouring in the
different decades : —

Years .

— 20

—30

—40

—50

over 60

Manic .

38.4

32-3

33-2

30.6

18.2

15.9

Manic-depressive

20.1

19.8

14.4

I3-I

17.2

15-9

Depressive .

•41. 1

47-9

52.4

56.3

64.6

68.2

172

MANIC-DEPRESSIVE INSANITY

The contrast in the behaviour of manic and depressive
attacks is very distinct. The greatest decrease of manic
attacks and the greatest increase of depressive attacks takes
place between the fifieth and the sixtieth year, somewhat
later than in the first attacks ; the depressions, which appear
in great number between the forty-fifth and fiftieth year,
have thus the tendency to be repeated in the same form. In
general, attacks composed of a sequence or a mixture of manic
and depressive phenomena decrease likewise with age, yet
they appear after the fiftieth year partly to take the place of
the manic attacks, which decrease in disproportionately great
measure. Unfortunately combined and mixed attacks were
not^kept separate from each other ; 1 suppose that the former

■■ Manner (25j t-aiiej
CD Frauen (648 F«Ue)

Vears 10 15 W

M. 2S.0 -M.l aV7 2!<.:i at.O ■»' :12.1 III. 7 2i..l W.l .'U.:! ai.:t 36.:i

Fig. 47. — Share of the sexes in manic-depressive insanity (first attacks)
at the various ages.

predominate in youth, the latter in age. In any case it can
be said with certainty that in manic-depressive insanity
depressive attacks are progressively substituted for manic
attacks which at first are almost equally frequent.

The form of the clinical states in detail appears also to be
influenced by age, a question about which more minute in-
vestigations are necessary. While of the depressed cases,
with simple delusion of sin and indefinite ideas of persecution,
37.6 per cent, had not yet passed the thirtieth year at the
commencement of the disease, only 35.3 per cent, of those
with well-marked, and often extraordinary delusions re-
mained under that age. Delusion seems thus to be some-
what inore active in the later years of life, as we saw in
dementia praecox. In the forms running a circular course
also, very elaborate delusions certainly come under observa-

CAUSES

173

tion even in youth. The cases with states of profound
anxiety belong with great preference to the later years ;
only 12.7 per cent, of any cases were under the thirtieth year.
This circumstance also formerly strengthened me in the
opinion, that a special place must be made for " climacteric
melancholia."

Of the manic forms the slighter appear to begin at an
earlier age ; 66 per cent, of that kind of case began before

Years 10 15 20 25 30 35 40 45 50 56 60 65 70 75 80 85
3 18 140 154 199 147 132 89 107 82 51 47 17 — 1 1
1 6 51 55 60 66 65 47 48 42 34 18 15 6 — 2

Fig. 48. — Distribution of 1704 attacks of manic-depressive insanity at the

various ages.

the thirtieth year, against 58.4 of the states of severe excite-
ment. Further we find in youth specially the cases with
more severe clouding of consciousness, confusion, and states
of stupor ; 67.6 per cent, of these began before the thirtieth
year. It would not be inconceivable, that here the tendency
of youth to hysterical disorders, in especial to dazed states,
influences the clinical picture. The cases with compulsive
ideas had all begun before the thirtieth year ; a specially

174 MANIC-DEPRESSIVE INSANITY

severe and peculiar morbid predisposition might be the
foundation of these.

Sex. — The share of the two sexes in manic-depressive in
sanity is very varied. Among ourselves about 70 per cent,
of the patients belong to the female sex with its greater
emotional excitabihty. Peixoto reports what is worthy of
note, that in Brazil there are among the men 6.2 per cent,
manic-depressive patients, among the women 6.8 per cent.
In general the women fall ill somewhat earlier ; of them 49.7
per cent, were at the commencement of the malady under
thirty years of age. of the men only 45.5 per cent. The share
of the two sexes in the cases at the various ages is shown in
Fig. 47. The share of the women is greatest in youth up to
the years of development, and in the time between the twenty-
fifth and thirtieth year and lastly in the climacteric. The
processes connected with sexual life, the beginning of the
menses, which not infrequently starts the first attack,
parturition and puerperium, and also involution, without
doubt here play a part. In more advanced age the share of
the male sex is greater ; injuries caused by hfe, among which
arteriosclerosis appears to have a certain significance, may be
causal factors. But the decrease in frequency of cases among
women in more advanced age is probably more important for
the displacement of the ratio.

In order to have a clearer view I have illustrated in
Fig. 48 the distribution of 516 attacks among men and 1188
attacks among women in periods of five years according to
the original figures. The greatest frequency of the attacks
among women is seen between the twenty-fifth and thirtieth
years ; among men, where the fluctuations are much less, it
falls somewhat later. Very noteworthy is the decrease of
attacks among women before, and the increase after the
forty-fifth year ; the explanation might be found in the
cessation of the work of reproduction on the one hand, in the
commencement of the involutionary processes on the other.
A considerable part of the general fall in frequency of attack
is, of course, due to the death-rate. The fact appears all the
more striking that also in the male sex after the forty-fifth
year not only a retarded decrease, but even a slight in».rease
of the cases becomes perceptible, a sign that here also a
certain unfavourable influence of the involutionary age is
present. The later diminution of the attacks takes place
relatively more slowly than among the women, although their
longevity should give them a preponderance.

69.4

73-6

77-8

56.8

55-3

51.2

62.9

72.7

8i.o

57-6

69-9

78.8

CAUSES 175

The share of the sexes in the principal clinical forms is
shown in the following summary : —
Years . . . — 20 — 30 — 40 — 50 — 60 — 70

A. — States of Depression.
First attack, Men . 46 . 7 53 . 5 58 . 3
Attacks in general,

Men . . . 39.7 48.7 43.5
First attack.

Women . .20.0 39.7 54.7
Attacks in general,

Women . .41,6 47.6 56,6

B. — Combined and Mixed States.
First attack, Men .26.6 12.7 16.7 8.4 20.5 21. i
Attacks in general.

Men . . .24.1 14.8 16.0 7.4 18.4 14.7
First attack.

Women . .51.5 42.2 33.6 23.7
Attacks in general.

Women . .18.6 21.5 13.7 14.3

C. — Manic States.
First attack, Men .26.7 33.8 25.0 22.2
Attacks in general.

Men . . . 36.2 36.5 40.5 35.8
First attack.

Women . .28.5 18.0 12.7 13.4 3.6 —
Attacks in general.

Women . .39.8 30.9 29.7 28.1 13.5 4.6
If we now consider only the first attacks, we see that
among women states of depression in youth are relatively
considerably rarer than among men ; in their place com-
bined forms appear more than any other, which, apart from
the most advanced ages, remain permanently far more fre-
quent than among men. The difference in the frequency of
first attacks of depression certainly disappears more and
more, especially after the fiftieth year ; the same is true for
the combined forms. Manic first attacks are, except in early
youth, much rarer among women. In the male sex the fre-
quency of states of depression increases continuously with
age, to a considerable extent before the fiftieth year, with
simultaneous decrease of the combined forms. Manic first
attacks after an increase at the beginning, become progress-
ively rarer and in more advanced age disappear almost

23.7

19.0

16.6

5-9

I.I

26.3

34.1

176 MANIC-DEPRESSIVE INSANITY

entirely ; they are associated more and more with phenomena
of depression.

The total number of attacks shows a frequently divergent
picture. The increase of depressive states with age is here
substantially less and more irregular, a sign that these have
less tendency to frequent repetition than the manic and
combined forms. On the other hand the decrease of the
frequently returning manic attacks is much less, especially
among the men. They come more into the foreground here
because of their great tendency to relapse, among women
chiefly at the expense of the combined forms, among men of
the depressive forms. In consequence of this the difference
between the sexes in the frequency of the depressive, as well
as of the combined attacks is almost completely obliterated ;
the share of the manic attacks among the women remains,
however, permanently smaller after the twentieth year.
The circumstance is noteworthy, that the share of states of
depression in all the attacks taken together among men is
permanently smaller, among women on the other hand at first
greater than in the first attacks. That signifies that these
states exhibit among men a slight tendency, but among
women, at least in the first decades, a great tendency to
similar recurrences. In the combined form, especially
among women this tendency is obviously slight ; in their
stead manic attacks appear later by preference. As the
general result of these considerations it can, therefore, be
stated that men comparatively often have attacks of de-
pression with sHght tendency to repetition, but then also
have manic attacks which often recur. Women on the other
hand begin most frequently with combined attacks or mania ;
moreover, periodic depression often occurs among them,
which only in later years gradually gives place to simple
attacks.

With regard to the frequency of the individual clinical
forms, the investigation gives the result that among men
states of simple depression appear to be more frequent,
among women on the contrary those with extraordinary
delusions or with anxiety. In the male sex further purely
manic attacks are more frequent, while among women we often
find combined attacks, and stuporous and confused states.

The length of the intervals between individual attacks
appears to be not essentially influenced by the sex of the
patient. According to my classification it amounted for
both sexes after the first attack to 4.6 relatively 4.3 years,

Depressive.

Manic.

Combined forms

64.2

8.3

27-5

35.6

■23-3

41. 1

45-5

24.4

30.1

35-3

II. 7

53.0

CAUSES 177

after the second attack to 2.8 relatively 2.0 years, after the
third and subsequent attacks to 1.2 relatively 1.4 years.
If any value is placed on these differences, at most it might
be said that women at first usually have a recurrence sooner
than men.

Personal Idiosyncrasy is, as Reiss also demonstrated
lately, without doubt a coefficient for the clinical form of the
disease, unless from the other point of view it must be re-
garded as already the expression of the existing malady.
While on the average the proportion of manic, depressive,
and combined forms in the patients with recognizable morbid
temperament, quite corresponded to the general frequency
otherwise of those forms, the behaviour was seen in detail
to be according to the following summary of percentages : —

Depressive Temperament .
Manic Temperament .
Irritable Temperament
Cyclothymic Temperament

It is seen that from the depressive temperament preferably
states of depression arise, while purely manic attacks are rare.
As the latter meanwhile with the combined forms still make
up a third of the cases, the moodiness arising on a depressive
foundation will scarely be able to claim a separate clinical
position. From the other side we see, namely, that with the
manic temperament the depressive cases only amount to a
little over a third of the total. The preponderance of manic
forms alone is certainly by a long way not so considerable as
that of the depressive forms in the first group, but there we
probably have only the expression of the general pre-
dominance of states of depression among ourselves in con-
trast to the behaviour of the Javanese patients mentioned
above. The irritable temperament yields morbid forms
almost in the average distribution, but rather more manic
and rather fewer combined forms. It might accordingly be
the most general as weU as the most frequent, and exercise
the least influence on the special form of the clinical picture.
Finally, the cyclothymic temperament appears, so far as the
small numbers permit of a judgment, to favour the develop-
ment of combined forms, which in any case is obvious.

External Influences. — Compared to innate predisposition
external influences only play a very subordinate part in the
causation of manic-depressive insanity.

178 MANIC-DEPRESSIVE INSANITY

Alcoholism occurs among male patients in about a quarter
of the cases, but is to be regarded as the consequence of
debaucheries committed in excitement, not as a cause. Now
and then an alcohoUc colouring of the attacks is observed,
which may reveal itself in very vivid auditory hallucinations,
hearing long dialogues of not very flattering character,
seeing illusions with reflectors, visions of animals, night
terrors with heavy perspiration and trembling. Sometimes
I have seen a manic attack begin with well-marked delirium
tremens.

I found syphilis in about 8 per cent, of my male patients ;
it is, however, to be judged from the same point of view.
Ziehen has certainly described cases of periodic or circular
psychoses, which he traces back to acquired or inherited
syphilis. According to my view it can only be a case there
of the fairly frequent association of manic-depressive morbid
phenomena with syphilis or of syphilitic psychoses with
circular forms, but not with a circular insanity engendered
by lues. It is noteworthy that manic-depressive patients
very rarely fall ill of paralysis, while symptoms of cerebro-
spinal syphilis are not altogether rare among them.

Recently it has been emphasized by Pilcz and others that
manic-depressive insanity is often connected with coarse brain
disease. Pilcz reports seven cases of apoplexy, which the
malady is said sometimes to follow closely, further ten cases
with tangible brain conditions. Hoppe, who twice found
cysts of the pia, thinks that brain scars act to a certain
degree as irritating foreign bodies and so bring the psychic
disorder to development. Saiz and Taubert have described
cases with brain scars. Neisser saw a circular psychosis
appear after an attack of apoplexy with paralysis. I myself
observed a patient in whom, after periodically returning states
of depression, which immediately followed an attack of
apoplexy with paralysis, a circular form developed. In spite
of all isolated experiences of that kind, it must still be
doubted, having regard to the enormous mass of cases
developing without tangible cause, whether it here concerns
more than chance coincidence. At most one might in a
similar way, as holds good for a great number of other in-
fluences, regard the irritation of brain scars as the exciting
cause of isolated attacks. Or one must assume that there is
a special " periodic focal brain psychosis," corresponding,
perhaps, to traumatic epilepsy. For this view there are,
however, up till now scarcely sufficient grounds forthcoming.

CAUSES 179

The number of other causes, which are made responsible
for the appearance of attacks, as well as for the origin of the
whole malady, is extraordinarily large, a sure sign that no
single one of them possesses really decisive significance.
First, head injuries might be named, which, indeed, might
produce brain scars in the sense just indicated. Monke-
moller, in the previous history of fifty-six cases of periodic
insanity, found thirteen cases of cranial traumata. Among
my own observations also there was a series of similar cases.
But the head injuries had almost always occurred many years
and even decades before the outbreak of the disease, and
they were almost entirely absent in the female sex with its
special tendency to manic-depressive insanity. As real
causes of this malady they can, therefore, not be taken into
consideration.

The same holds true for the bodily illnesses which, not
rarely, precede the development of manic-depressive insanity.
Typhoid, erysipelas, pneumonia, disease of the stomach and
ear operations, pleurisy, cholera nostras, influenza, blood-
poisoning, haemopt^^sis, were specified to us as causes.
Among twenty-eight cases of that kind, however, in seventeen
either there had been attacks of a similar kind previously
or they followed later without external occasion.

Far more frequently an attack of manic-depressive in-
sanity follows a confinement closely, or it begins during
pregnancy. Among thirty-eight cases of the former kind
similar attacks appeared twenty-five times, among ten cases
of the latter kind five times, also before or afterwards
spontaneously. A patient suffered from mania after two
confinements, but besides that frequenth^ from manic or
depressive attacks. Another woman fell ill first after con-
finements ; this happened three times and afterwards several
times spontaneously. A third became manic after a con-
finement and likewise after the death of a child, and de-
pressive after giving up her business, but also had otherwise
several manic and depressive attacks.

Psychic Influences. — A still greater role is usually
ascribed to psychic influences. In especial the attacks begin
not infrequently after the illness or death of near relatives.
Among forty-nine observations of that kind, attacks were
also observed twenty-four times without cause. A woman
fell ill three times of depression after the death first of her
husband, next of her dog, and then of her dove. Another
patient was depressed after the death of her husband, manic

i8o MANIC-DEPRESSIVE INSANITY

after a confinement and after a dental operation. Again,
another became depressed during pregnancy, and manic after
the death of her husband, but on other occasions she had
attacks of various colouring. The case of another patient
was similar, who became depressed after a fright and after
the death of her uncle, and manic after her mother's death.
Still another fell ill of mania after a confinement and after
the death of a child, and of depression when she gave up her
business.

That here incalculable accidents have their share is shown
by the case of a patient who frequently suffered from manic
and depressive attacks ; she became depressed after an
operation and after the suicide of her fiance, but stood the
death of her mother without falling ill. Another fell ill first
after an abortion brought about by herself, and again after
a confinement, but in the interval gave birth to a child with-
out suffering from any disorder.

Among other circumstances there are occasionally
mentioned quarrels with neighbours or relatives, impending
or threatened law suits, fear of a misfortune, disputes with
lovers, unrequited love, excitement about infidelity, financial
difficulties, losses, purchases, sales, removals, fatiguing sick-
nursing ; engagements also and the first sexual intercourse
are sometimes the occasion of an attack. Among forty-five
patients, whose attacks were traced back to such ca\ises, there
were twenty-seven, who also otherwise had similar attacks.
A man fell ill after an advantageous purchase of depression,
but had suffered from it already previously. In another
case the sale of a property, which was regarded as the cause
of a depression, was successfully made null and void, but
without any influence on the disease ; later on there were
further manic and depressive attacks.

The certain conclusion, which can be drawn from these
and similar extremely frequent experiences, leads us to this,
that we must regard all alleged injuries as possibly sparks for
the discharge of individual attacks, but that the real cause
of the malady must be sought in pennanent internal changes,
which at least very often, perhaps always, are innate. At the
same time the individual case may strongly suggest the
assumption of close causal relations between external
occasion and attack. Thus a man fell ill of depression first
after the death of his mistress, then after that of his wife. A
woman twice became melancholy, each time after the death
of a brother. If such attacks remain the only ones in life.

CAUSES i8i

nothing appears more natural than to see in such melancholias
the increase of well-founded grief going on to morbidity.
That this interpretation is not appropriate, the cases prove,
in which the morbid state differs completely from that of the
discharging emotional shock, by the development of extra-
ordinary delusions or by manic colouring. Further, the
observations are instructive in which, in spite of the removal
of the discharging cause, the attack follows its independent
development. But, finally, the appearance of wholly similar
attacks on wholly dissimilar occasions or quite without ex-
ternal occasion shows that even there where there has been
external influence, it must not be regarded as a necessary
presupposition for the appearance of the attack.

Certainly it happens that further independent attacks are
often absent, or they are difficult to prove.- Of two women,
who both had depressive attacks on the death of their
husbands, the one had already had an attack thirty-seven
years previously ; the other fell ill twenty-one years later
in the same way without occasion. If, however, a survey
is made of a larger series of observations, it can be easily
seen that exactly the same clinical states attain to develop-
ment, the one time in close association with injuries of the
kind mentioned above, the other time quite independently
of them, and that between these two limiting cases all
imaginable transition states are demonstrable, not only in
different patients, but also in one and the same case. Un-
fortunately the powerlessness of our efforts to cure must
only too often convince us that the attacks of manic-
depressive insanity may be to an astonishing degree in-
dependent of external influences.

Nature of the Disease. — About the nature of manic-
depressive insanity we are still in complete uncertainty.
Both the frequent return of the attacks and the peculiar
alternation of excitement and inhibition are complete
enigmas. We may first of all refer to the fact that in our
nerve tissue the tendency to a periodic course of inhibitory
and excitatory processes occurs in the most different domains.
Meynert has searched for the explanation of the alternation
of opposed states in periodic disturbances of vasomotor in-
nervation. In consequence of increased irritability of the
vasomotor centre, a state of reinforced tension is said to be
developed in the whole arterial field with simultaneous
cerebral anaemia as cause of the depressive moodiness. And
exactly the deficient nourishment of_the vasomotor center

i82 MANIC-DEPRESSIVE INSANITY

caused in this way is then said further to bring about a
paralysis of the centre itself, dilatation of the vessels, and
hyperaemia of the brain, and the development of manic-
excitement is regarded as the expression of this. It is in-
dubitable that changes in the behaviour of the pulse corre-
spond to the two periods of an attack ; for the rest, however,
the view given reckons with wholly unknown quantities. It
would also be difficult to reconcile with the fact of single
attacks lasting for years and even for decades, and moreover
fails completely at the fact of the mixed states.

The very considerable fluctuations of body-weight might
here also suggest more general changes in the metabolic pro-
cesses, but our knowledge is not sufficient to provide useful
points of view. Lange ^ has assumed as the foundation of
periodic depressive states with psychic inhibition, which
indubitably belong to the domain of the malady here
described, a gouty mode of development, a view which, how-
ever, till now cannot be regarded as proved or even as prob-
able. Stegmann found in " periodic neurasthenia," which
certainly belongs to manic-depressive insanity, diminution
of uric acid excretion at the time of the moodiness. Pardo,
who has carried out comprehensive investigations into the
" coprology " of the disease, is inclined to regard as its
essential foundation the intoxication of the body by the
metabolic products of intestinal bacteria. He observed during
the attacks a change and enrichment of the intestinal flora,
especially the appearance of a definite cocco-bacillus. He
also thinks that the attacks are frequently started by dietetic
errors and ended by diarrhoea, the two explanations would
scarcely be applicable to any extent worth mentioning. The
constipation beginning during the attack is said to be a
protective measure of the body which by digestion destroys
the injurious bacteria.

Parhon and Marbe suggest an insufficiency of thyroid
gland activity, Muratow a special significance of the supra-
renals for the development of the disease. Obviously in all
these unproved and unprovable views there is only the re-
flection of the influence of current opinion. Stransky also
searches for an explanation of manic-depressive insanity
from the point- of view of metabolic disorders. On the one
hand he directs attention to the indubitable near relation-
ship of this malady with other forms of insanity of degen-

^ Lange, Periodische Depressionszustande und ihre Pathogenesis auf
dem Boden der harnsauren Diathese, deutsch von Kurella, 1896.

CAUSES 183

eration, and emphasizes the ancestral relations between
emotional life and periodicity. Further, he supports his
views on the relations between Basedow's disease and manic
depressive morbid phenomena and conjectures auto-intoxica-
tion by glandular products, which specially influence the
vascular system, perhaps disorders in the metabolism of
iodides. Our patients are said to be by their peculiar pre-
disposition hypersensitive to those poisons or to be incapable
of counteracting them sufficiently.

The remarkable changes of state often beginning so
suddenly in the patients and the form of the clinical pictures
recaUing many intoxications (alcohol, products of fatigue),
lastly, the appearance of very similar states in paralysis do,
indeed, suggest the thought of internal poisons, but on the
other side again great difficulties stand in the way of this
view. The regularity, with which in many cases the alterna-
tion of states continues throughout a great part of a lifetime,
the almost unlimitedly long duration of the morbid states
without lasting injury to the psychic personality, the often
distinct exciting influence of emotions, lastly also, what is
emphasized by Stransky himself, the clinical and hereditary
near relationship of the malady with other forms of insanity
of degeneration would better fit an explanation of the morbid
processes, which laid the chief responsibility on an abnormal
behaviour of the nerve tissue itself. The circumstance is,
perhaps, also worth mentioning that in manic-depressive
insanity the special form of the picture appears to be in
greater measure dependent on the psychic personality than
we are accustomed to see it in pure effects of intoxication.

In connection with Morel and Doutrebente, Anglade and
Jaquin have chosen the relations between manic-depressive
insanity and epilepsy for the starting point of their con-
sideration. They lay stress on the fact, that the neuroglia
in both diseases presents an infantile appearance ; from this
we may conclude that there are hereditary abnormal
peculiarities in it, and that it may perhaps represent a patho-
logical anatomy of the predisposition. It concerns in both
diseases an interference with the state of equilibrium between
neuroglia and nerve tissue, of the kind that even slight causes
may call forth considerable disorders, it. may be in the sense
of epilepsy, or in the sense of " folic." The taking together
of the two diseases, which in the most different directions
diverge far from each other, seems to me to be just as little
a forward step, as their being traced back to a struggle

i84 MANIC-DEPRESSIVE INSANITY

between the two tissues which are opposed to each other, as
is said, " Uke two hostile sisters."

The opinion, which Thalbitzer has formed of the nature
of manic-depressive insanity, is hkewise connected with
pathological anatomy. As the foundation of the malady
he regards diseased vasomotor paths for the nourishment of
the brain, the course of which he relegates to the triangular
tract described by Helweg in the cervical spinal cord. A
peculiar fineness of the fibres, which causes the tract to
stand out more distinctly, is. said, as developmental in-
hibition, to prepare the soil for the appearance of vasomotor
disorders and with these of manic-depressive insanity.

CHAPTER XI.

DELIMITATION.

The morbid form of manic-depressive insanity, as it has here
been dehmited and described, is composed of a great number
of clinical component parts, which otherwise frequently
receive a different interpretation. The starting point of
the conception of the disease is formed by the doctrine of
the periodic, or, as Magnan named them, intermittent psychic
disorders. This doctrine was elaborated principally by the
French alienists. The attention of these investigators was
then directed to one of the most strking characteristics of our
morbid groups, to its tendency to multiple repetition in life.
At the same time it could not escape their notice that the
return of the attacks takes place sometimes in the same,
sometimes in changing form. This experience led next to
the separation of periodic mania and melancholia ; then, as
already mentioned, the compound forms were again divided
according to their changing course into a series of varieties
till they were collected later under the name of circular in-
sanity, which originally was valid only for the continuous
alternation of mania and depression.

Further experience, as it could not permit of the in-
dividual kinds of circular insanity being regarded as separate
diseases, has also taught that the separation of the simple
periodic forms from the compound cannot be carried through.
As before discussed in detail, the purely manic attacks with-
out any association with depressive symptoms, as intro-
duction, conclusion, interpolation, or admixture, belongs to
begin with to the rarities, and when we meet with one or
other attack of that kind, we yet see, as in our cases 7, 8, 9,
and 10, at least at another time depressive periods attain to
development. But the clinical pictures of the manic attack
itself resemble each other completely, whether they belong
to a so-called periodic mania or to a circular form. There
is no alienist, and, according to my conviction there can be
none, who would be capable of recognising from the picture
of the state alone, whether a given manic attack belonged to

i86 MANIC-DEPRESSIVE INSANITY

the one or to the other group of forms. Although the manic
attacks may diverge from each other ever so much, yet these
differences tell us absolutel}' nothing about whether we have
to do with a periodic mania or with a circular insanity.

The question in regard to periodic melancholy is con-
siderably more difficult. If we are convinced that in
periodic mania we have to a certain extent to do with a form
of circular insanity, in which all the attacks are changed into
the manic form, the idea is naturally suggested, that cases here
also occur, in which the depressive attacks alone hold the field.
This view gains fresh support from the fact that in associa-
tion with the states of depression not only can slighter in-
dications of manic symptoms be demonstrated with extreme
frequency, as temporary exalted mood, ideas of exaltation,
laughing, singing, dancing, feeling of happiness in the time
of recovery, but also between the pure periodic depressions
and the circular forms all conceivable transitions may be
seen. Finally, attention must still be called to the mixed
states for whose peculiarity and multiplicity we only gain an
approximate understanding, when we regard all the opposed
manic and depressive symptoms as equivalents, which can
mutually replace each other and actually do appear for each
other with extraordinary frequency.

In spite of all these weighty reasons, the extraordinary
frequency of the cases, which run their course in several or
many periods of purely depressive form without a trace of
manic features, stands in the way of the temptation to unite
without hesitation the whole domain of periodic melancholy
with circular insanity. It is in any case incomparably much
greater than that of pure periodic mania. Especially in
more advanced age we see numerous patients of that kind
with a few depressive attacks repeated in similar form, some-
what like our third case. But there is also the fact, that the
clinical form of depression in general is far less characteristic
of a definite disease than the manic type. While here in
the essential point only the deUmitation from paralytic
(syphiUtic) or catatonic states of excitement, perhaps also
once in a way from expansive paraphrenia, comes into
question, which for the most part is capable of rapid accom-
plishment, a state of depression may besides that be also of
psychogenic or arteriosclerotic origin, and it may further re-
present the introduction to one of the anxious or paranoid
psychoses of the involutionary years so little understood by us
as yet. Although we have grounds for the assumption, that

DELIMITATION 187

the composition of the clinical picture in all these cases will
show certain differences, it is yet up till now often scarcely
possible from the psychic state alone to come to a reliable
decision.

Certainly there is added in our case as an auxiliary character-
istic the return of the attacks. From the outset, however,
the possibility must not be disregarded, whether other forms
do not also possess this peculiarity. On the one hand the
cases appearing as a simple increase of a morbid, depressive
predisposition might have the same tendency without on
that account being related to circular insanity, on the other
hand the depressive attacks of the involutionary years which
do not recur often, even perhaps appearing only once. In
the former case further investigation has shown that from the
depressive predisposition states of depression, indeed, develop
most frequently, but that along with them periodic manias
also and combined attacks occur. There is thus no sufficient
reason forthcoming for separating off those first forms. But
for the comprehension of the last forms, observations, like our
cases 16 and 17, are instructive, in which it is seen that here
also in certain circumstances, after depression frequently re-
peated or lasting many years, manic periods may still be
developed. But further, as was formerly explained, it has
turned out that the predominantly depressive colouring of
states in the involutionary years only signifies the last part
of a general change of the morbid picture with advancing
age, which has begun already long before, and does not at
all permit of a fundamental separation of the depressive
forms of the involuntionary years. We are, therefore, forced
to the conclusion by all these considerations, that periodic
melancholy also is not an independent disease, but a form of
manic-depressive insanity. Its peculiarity consists only in
this, that it develops, certainly with a somewhat different
clinical signification, with special preference on the soil of the
depressive predisposition and further in more advanced age.

As periodicity was regarded as a very important char-
acteristic of disease, the periodic psychoses were from the
outset placed in opposition to those which appear only once
in a lifetime. The beginning was made with those cases, in
which throughout a considerable time an approximately
regular return of similar attacks actually took place. And
just that kind of example led to the making of sub-divisions,
which were characterized solely by the different relations
between the attacks and the free intervals. But the minute

i88 MANIC-DEPRESSIVE INSANITY

examination of a comprehensive series of cases very soon
teaches, as already the small selection of our examples shows,
that a Regularity, even only approximate, of the course forms
a comparatively rare exception among the recurrent cases.
In an overwhelming majority of the cases we have to do
rather with a wholly incalculable sequence of attacks some-
times more frequent, sometimes more rare, sometimes more
uniform, sometimes alternating or combined, between which
pauses are interpolated of extraordinarily fluctuating
duration. The greater number of these cases must of course
be excluded from the domain of the genuine periodic
psychoses. It was assumed that here it concerned " re-
lapsing " attacks of mania or melanchoUa or isolated attacks
quite independent of one another. That, of course, held
good especially for the cases with very few attacks in a life-
time or even with only a single one. Experience has
certainly everywhere shown that the number of such cases
on more accurate examination shrinks to a remarkable
degree, and simple mania at least becomes an always rarer
disease ' ; but without doubt there are cases enough in which
only a single attack of mania can be demonstrated thoughout
hfe.

It must meanwhile be emphasized that this fact, for the
establishment of which a series of investigators have exerted
themselves, is of very little significance for deciding the
question of the relations between simple and periodic forms
of mania and melanchoUa. What it depends on, is obviously
the ascertaining whether the return of the attacks in those
clinical forms represents an essential or a more secondary
symptom. In the former case we shall have to place the
" periodic " forms separate from the " simple " forms as a
special group, in the latter case not so.

About this question it must first be remarked that no
border line at all can be drawn between the strictly periodic
forms and those which run an irregular course. Of special
significance for this question is the fact, that a periodicity,
in some degree satisfying, exists in numerous cases only for a
certain part of the course, that it develops first in the course
of the malady or even again disappears. This proves that
here it concerns not a fundamental and inviolable p)eculiarity
of the morbid process but a fluctuating characteristic ; the

' von Erp Taalman Kip, Allgem. Zeitschr. f. Psychiatric, liv. 119;
Hinrichsen, ebenda, 86 ; Mayser, Archiv f. Psychiatric, xxxi. 500 ; Parant
Annales m6dico-psychol.. 1910, 68, 395.

DELIMITATION 189

cases with a very regular course are not fundamentally dis-
tinct from the others. Moreover, we see a similar, more or
less incomplete periodicity develop also in a series of other
diseases, particularly in epilepsy, also in hysteria, and in
certain forms of dementia prsecox especially in their terminal
states. We conclude from this also that the periodic re-
currence of morbid attacks cannot be the standard character-
istic of a definite morbid process.

That which decides whether a case of illness belongs to a
certain disease or not, is rather the incontrovertible placing
of the clinical details within the hmits of the known forms.
But no one will wish to deny that between the individual
attacks of the strictly periodic forms and of the forms which
only " relapse," whether manic or melancholic, the most
perfect agreement exists. All attempts to find here any
useful distinguishing characteristics have completely failed.
We shall be able, therefore, to give up the boundary between
strictly periodic and irregularly recurring forms and bring
them all together to a unity.

But quite similar considerations hold good for the number
of attacks in the individual patient. We know cases, in
which many dozens of attacks in unending series have to be
recorded. Then there are patients with six, eight, ten
attacks in life which follow one another with fairly long
pauses intervening. If it is admitted that these cases belong
to periodic insanity, so neither can it be denied of the cases,
where perhaps every fifteen or twenty years from the period
of development an attack breaks out, thus altogether three
or four during life. But who will assert that here the limit
of " periodic " insanity is finally reached ? There are, as
we have seen, cases in which twenty, thirty, indeed, more
than forty years pass between the attacks ; naturally here
the number of possible attacks in general is restricted at most
to two or three, especially when the malady begins first in
more advanced years.

As can be seen, it might be admitted that even the cases
with only one attack belong to a strictly " periodic insanity "
by the assumption of very long pauses. Since, however, in
the form here discussed we are not at all concerned with an
actual periodicity, but only with a tendency, sometimes
stronger, sometimes weaker, to the recurrence of the same
disorders, we are not at all in need of such subtleties. What
rather solely and alone concerns us is, as ever again must be
emphasized, the fundamental and complete agreement of the

190 MANIC-DEPRESSIVE INSANITY

general clinical morbid picture. We are wholly incapable of
judging by one manic or melancholic attack, whether it will
remain the only one in life, or will recur several times, or even
very frequently ; only the further following up of the case,
which assuredly under certain circumstances would have to
be continued for thirty years and more, can clear up the matter
for us. At most subsidiary circumstances, the existence of a de-
pressive or manic predisposition, an attack in early childhood,
the occurrence of frequent attacks in the parents or brothers
and sisters, the general probabiUty of recurrence, give special
help ; also the combination of manic and depressive periods
could be made use of in this direction. But beyond that all
evidence is lacking. Neither does the subsequent examina-
tion of attacks appearing only once or repeatedly disclose
characteristics of any kind which permit of a separation.
These are the reasons, which have caused me to gather into
the unity of manic-depressive insanity, besides the circular
attacks, not only the periodic and relapsing forms, but also
the simple forms of mania and melancholia.

A difficulty stood in the way of this conception, namely,
the peculiar cHnical form of the depressive states of more
advanced age. Without regard to the fact already discussed,
that here in general a very conspicuous tendency to de-
pressive attacks appeared, which must arouse the suspicion
of morbid processes of a peculiar kind, very frequently also
in these forms volitional inhibition which otherwise is so
characteristic of depression was absent, and often also in-
hibition of thought. In their place anxious excitement
appeared, mostly with abundant delusions. Moreover, the
course was very chronic, so that frequently after a fairly
long series of years still no recovery had taken place, but
rather the issue in a state of mental weakness seemed to
have begun. A number of patients were also indubitably
demented.

Under these circumstances I had at first thought that
I should separate that kind of depressive attack of the
involutionary years as a special clinical form, as " melan-
cholia " ^ in the narrower sense, from manic-depressive
insanity, since here with regard to the composition of the
state, of the course and issue, in a certain sense with regard
also to the history of origin, essential divergencies appeared
to exist. At the same time I did not conceal from myself,

1 Hoche, Die Melancholiefrage, 1910 ; Volpi-Ghirardini, Ri vista di
freniatria spcrim, xxxvi. 161.

DELIMITATION 191

that in a whole series of depressive states of the involutionary
years the fact that they belong to manic-depressive insanity
could not be doubted both on account of their clinical form
and also an account of their earlier or later association with
manic phenomena. I therefore strove to find some useful
distinguishing characteristics, certainly without an}^ satis-
factory result.

Further experience then taught, as in the discussion of
the presenile psychoses has already been explained, that the
arguments in favour of the separation of melancholia, were
not sound. The dementias could be explained by the
appearance of senile or arteriosclerotic disease ; other cases
after very long duration of the disease, some of them dis-
playing manic symptoms, had yet still recovered. The
frequency of depressive attacks in advanced age we have
come to recognise as an expression of a general law which
governs the change of colouring of the attack in the course
of life. Lastly, the substitution of anxious excitement for
volitional inhibition has proved to be behaviour, which we
meet with in advancing age in those cases also which decades
previously had fallen ill in the usual form, as our first and
second examples demonstrate. Hiibner has likewise had the
experience, that melancholic attacks may run their course
sometimes with, sometimes without inhibition. There is,
therefore, no longer sufficient cause to separate from manic-
depressive insanity the depressive states of more advanced
age, which till now have been called melancholia.

A further, not inconsiderable addition to this morbid form
was furnished by the mixed states, which so far had been
classified each according to its colouring under the most
different terms, as stupor of exhaustion, as acute dementia,
amentia ^ and so on. Here at the first glance the principle
laid down above appears to fail, that the form of the whole
clinical morbid picture must be authoritative in order that
it may be assigned to a disease, since the mixed states
frequently fall outside the limits of the ordinary states in a
very conspicuous way. The changes in the composition of
the clinical phenomena observed in the transition periods
between mania and melancholia served here as guide. They
taught us that our customary grouping into manic and
melancholic attacks does not fit the facts, but requires
substantial enlargement, if it is to reproduce nature. At
the same time it turned out that this enlargement ran out in

' Confusional or delirious insanity.

192 MANIC-DEPRESSIVE INSANITY

the direction not of the fitting in of fresh morbid s5miptoms,
but only of the different combination of morbid symptoms
known for long. Further, it was seen that the mixed states,
even when they appeared not as interpolations but as
independent attacks, behaved with regard to their course
and issue quite similarly to the usual forms, and lastly, that
they might in the same morbid course simply take the
place of the other attacks especially after a somewhat long
duration of the malady. With all these estabhshed facts
the proof that the mixed states belong to manic-depressive
insanity appears secure.

From still other directions morbid forms have been drawn
into the territory of manic-depressive insanity. Specht and
Nitsche have rightly pointed out that a number of querulants
who used to be reckoned to paranoia, are in reality nothing
but persons with manic predisposition. Specht has even
made the attempt which certainly goes too far, to let the
whole of paranoia be included in " chronic mania," delimited
by himself, which in essentials is covered by the manic
predisposition here described.

On the other hand, Hecker and Wilmanns have
emphasized that a considerable number of the patients
described as psychopaths, neurasthenics, hysterics, suffer
from cyclothymic fluctuations of mood, and, therefore,
likewise belong to the domain of manic-depressive insanity.
That naturally holds good very specially for " periodic
neurasthenia," Dreyfus then, following Wilmanns, ascribed
in particular nervous dyspepsia essentially to cyclothymic
moodiness. Kahn spoke of " circularisme visceral," which
is said to be characterized by alternation of diarrhoea and
constipation. Finally, in agreement with Bleuler I think
that I may without hesitation include in manic-depressive
insanity " periodic paranoia " which nms its course in
isolated attacks with favourable issue, since it is invariably
accompanied by distinct fluctuations of mood, frequently
also by transitory states of excitement, confusion, or stupor,
and cannot be in any essential point dehmited from states,
which otherwise also we now and then meet in the course of
indubitably manic-depressive psychoses.

It cannot be denied that by all these new acquisitions
the range of manic-depressive insanity has increased to a
very considerable extent. That in itself is, of course, no
reason for doubting its unity, as little as perhaps the
frequency and multiformity of tuberculosis or of syphilis

DELIMITATION 193

can arouse in us hesitation about the dinical states. For
the present also I see no possibility of undertaking to make
fundamental divisions anywhere in this wide domain. On
the other hand the attempt may well be made to characterize
stil] somewhat more precisely individual sub-groups as to
their clinical peculiarities. In this direction Reiss has made
an experiment with the forms which grow on the soil of
well-marked manic-depressive predisposition, while Hecker,
Hoche, Wilmanns, Romheld have described minutely the
important morbid state of cyclothymia to which also probably
in essentials " neurasthenic melancholia " described by
Friedmann 1 must be reckoned. Dreyfus has given us a
glimpse, though certainly still incomplete, into the specific
character of the forms developing in more advanced age.
Specht and Nitsche have set forth in detail the behaviour
of the permanent manic states. Although the same morbid
process lies at the foundation of all these forms, they are
yet so different in clinical behaviour, in course, and in
prognosis, that one might perhaps speak of a morbid group
springing from a common root with gradual transitions
between the individual forms, rather than of a uniform
disease in the customary sense of the word.

Mugdan - has recently made the attempt to separate from
the circular attacks the " alternating " cases as a special
clinical unity. In these, which do not quite amount to a
third of the cases of " manic-depressive insanity," we find
only purely manic or depressive states, in the circular cases
a conjunction of both. The former are said to be further
distinguished from the latter by the greater frequency of
hallucinations and delusions, by more infrequent attacks,
and by more favourable prospects of cure. From my own
experience I can confirm the fact, that cases with close
association, and especially mixture, of manic and depressive
phenomena are in general to be regarded as more severe ;
but I do not consider it possible in view of the numerous
transition forms to draw any boundary at all here.

The extraordinary enlargement of our conception of the
disease is subjected on the other hand also to noteworthy
limitations. It must first be remembered that only a part of
the cases formerly called " mania " and " melancholia "
have been included in manic-depressive insanity. A con-
siderable number of cases, which formerly were taken

^ Friedmann, Monatsschr. f. Psychiatric, xv. 301.

^ Mugdan, Zeitschr. f. d. ges. Neurol, u. Psychiatric, i. 242.

194 MANIC-DEPRESSIVE INSANITY

together under those names, have been included in dementia
praecox, many also in toxic insanity and other smaller morbid
groups. But also from the periodic cases certain forms have
been split off. Without regard to circular paralysis, which
we can delimit to-day with certainty, dipsomania must be
remembered, which formerly was often reckoned to periodic
melancholia, but which to-day has a place given to it in
several groups. Further we are convinced that dementia
praecox also presents cases with a periodic course, which
according to their other behaviour must be removed from
manic-depressive insanity.

The so-called delusional forms still make up a disputed
domain. As far as I can judge at present, I do not think
that the morbid conception of delusional insanity is a unity.
I would without hesitation reckon it with manic-depressive
insanity. There certainly occur, as I have already indicated
above, states which are externally very similar, in certain
diseases of the involutionary age ; these run a very unfavour-
able course, and obviously are the expression of widespread
destructive processes in the cerebral cortex. The clinical
pictures, however, remind one more of catatonic morbid
forms. " Manic delusion," which is defended by Thalbitzer,
might likewise include component parts of different kinds,
at one time perhaps chronic manic cases with well-marked
delusions, but at another, cases of expansive paraphrenia,
with unfavourable issue, which has already been described
elsewhere.^ Certainty about these questions can only be
obtained by further investigation of this domain, especially
from the anatomical side.

' Kraepelin, Dementia Pracox and Paraphrenia. Translation ICdinburgh,
p. 302. (Oct. 1919).

CHAPTER XII.

DIAGNOSIS.^

The diagnosis of manic-depressive insanity is easy in those
cases, in which a series of alternating or similar attack^ has
already preceded. In the meantime it must be noted that
also in paralysis and in dementia praecox a similar alternation
between excitement and mournful moodiness or stupor may
occur just as here. In such cases the distinction must take
account of the peculiar clinical symptoms of the attacks
themselves, which we have already discussed in detail.

The slighter and slightest forms of manic-depressive
insanity pass over quite imperceptibty into the forms of
the morbid predisposition which we described before. In
the cyclothymic forms the periods of groundless moodiness
or unrestrained merriment may for long be considered as
simple capriciousness, and brought into connection with all
sorts of chance occurrences. Such patients, who perhaps
never come into the hands of the alienist, are, as Hecker
very properly has emphasized, frequently judged by the
physicians, who are consulted, solely according to moody
states, and they are considered to be hypochondriacs or
neurasthenics, as in the corresponding manic periods they
pass as healthy. Very frequently, however, in the period
of depression which drives them to the physician, they have
themselves a distinct feeling of the morbidity of the excite-
ment, of which they are sometimes very much afraid. It
is, therefore, in most cases easy to find out the alternation
of states and the recurrence of the individual attacks and
thus the nature of the malady in question.

Simple irresolution appearing suddenly without cause
is so specific that it often without anything more furnishes
the right key for the interpretation of the state. Such cases
are extremely frequent, and are found everywhere in
sanatoria, where they go through the most varied" cures. If
the cure coincides exactly with the transformation of mood,

' Bornstein, Zeitschr. f. d. ges. Neurol, u. Psych, v. 145 ; Thomsen,
AUgem. Zeitschr. f. Psych. 1907, 631.

196 MANIC-DEPRESSIVE INSANITY

it attains a brilliant result, which now is ascribed to it, but
unfortunately the same result does not appear, when the
patient the next time in the beginning of the attack hopes
for healing from it. Moreover, here also the people in the
surroundings may at any time be surprised by a severe
attack, although mostly the whole lifetime usually passes
in an alternation between all sorts of wild actions and the
presumed repentance for them, between feverish delight in
enterprise and the apparent reaction after overwork.

It is often essentially more difficult to judge of the
permanent manic or depressive states. Patients of the
former kind, who frequently fall into conflict with their
surroundings and with the public authorities, are mostly
considered to be swindlers, or rascals, often even to be
suffering from moral insanity. Without having regard to
the fluctuations of the state, with which also once in a while
a short transformation to depressive mood may be associated,
the clinical picture is also helpful in leading to a more correct
view, the permanently confident, self-righteous, often jovial
mood, the lively emotional excitability, the aimlessness,
unsteadiness, and the great busyness, the inaccessibility to
admonition, regulations, and unpleasant experiences, the
jocular derailments, the absence of criminal intentions.
Just these states, but also hypomanic attacks, which run
a very chronic course, present not infrequently the picture
of querulants. Whether the quenilant delusion, as Specht
thought, is in general to be conceived as a form of manic-
depressive insanity, will be discussed later. Here I would
only remark that manic vohtional excitement, otherwise
than in the delusional querulant, is invariably conspicuous
in the whole conduct of life, not only in common legal
relations. Moreover, the manic querulant displays as a
rule a more amused, exultant mood with an inclination to
humorous tricks, in contrast to the measureless exasperation
and animosity of querulant delusion. Finally in him, the
manic patient, fluctuations of the state are frequently
conspicuous, which under certain circumstances may cause
a sudden, repentant renunciation of the struggle till then
carried on passionately.

The permanent state of depression is perhaps to be
regarded as less unequivocal as an expression of the manic-
depressive predisposition. Where, however, distinct fluctua-
tions in the severity of the states, exacerbations of the
nature of a seizure, or even an occasional transformation

DIAGNOSIS 197

to unfounded merriment are observed, the relation cannot
be doubted. Peculiar caution in judging is required with
regard to compulsive ideas and obsessional fears, which
only exceptionally make their appearance in well-marked
attacks in manic-depressive insanity. Besides that there
remains to be noticed the permanent disposition, which in
depressive moodiness is gloomy and hopeless, in compulsion
neuroses on the contrary stands in the closest connection
with the appearance of the compulsion phenomena. The
patients may in the latter, when they are diverted, especially
also in conversation with the physician, be quite calm and
even cheerful, while the psychic oppression, which accom-
panies the depressive predisposition, is usually much less,
or not at all accessible to momentary external influence.

To decide whether an isolated state belongs to manic-
depressive insanity or not without a survey of the whole
course, is not always easy. The principal difficulties arise
in general with paralysis and dementia prcecox. If in the
former disease cytological and serological TfivgSttgation has
now made certainty very great, the distinction between the
states of manic-depressive insanity and of dementia prsecox,
simple as it is in the great majority of cases, may under
certain circumstances be very difficult. The points of view,
which here come into consideration, have been already
explained in detail.^ Here it will merely be added that to
decide between the two diseases, the consideration of their
history of origin may be of value. As manic-depressive
insanity in general begins somewhat earlier, the probability
in this direction will be somewhat greater in an attack before
the twentieth year. Moreover, attacks in advanced age
will much rather rouse the suspicion of manic-depressive
insanity. A well-marked manic or cyclothymic pre-
disposition scarcely leads to dementia praecox ; also the
occurrence of mania or melancholia in parents or brothers
and sisters will point in this direction, though certainly
by no means absolutely. The question is more difficult to
decide in individuals with depressive or irritable pre-
disposition. It appears that here we must keep separate
several, externally similar forms. Softness, sensitiveness,
dejection, lack of self-confidence are found to a greater
extent in the previous history of manic-depressive insanity,
shy, whimsical, repellent conduct in that of dementia prsecox.
Further, to the former correspond the easily inflammable,

1 Dementia Prcecox and Paraphrenia, p. 260.

198 MANIC-DEPRESSIVE INSANITY

sentimental, passionate natures, to the latter the incalculable,
stubborn, rough, and violent natures.

The least occasion for mistaken diagnoses is given in
general by manic states. Leaving aside paralytic and
catatonic states of excitement, only the confusion with
cerebral syphilis really comes under consideration, in which,
although not exactly often, states are observed, which
display very great similarity with manic states. The diffi-
culties may be increased up to the impossibility of a certain
decision, when not only the chance combination of mania
with lues exists, but also one or other of the morbid symptoms
as well, which point to the nerve tissue having a share in the
syphilitic disease, loss of pupillary reflexes, difference in the
reflexes, tabetic phenomena. Such cases are not altogether
rare. If there are disorders of speech and writing, seizures
with unconsciousness or even convulsions, one will be obhged
to think of a syphilitic foundation for the whole state, and
likewise when with relatively shght excitement and preserved
sense, gross disorders of memory, weakness of judgment,
and emotional dulness are conspicuous. If, however, it
should turn out that the first-mentioned bodily symptoms
have existed already for years unchanged, and, if the patient
with increased distractibility is clever, quick at repartee,
witty, his mood exultant, his conversation and actions in
fine style and clever, the probabiUty of mania with lues
becomes greater. It becomes an almost absolute certainty,
if already previously similar or depressive attacks have been
present. In certain circumstances also the exhibition of
anti-syphilitic treatment may clear up the situation ; a rapid
and obvious result would speak for cerebral syphilis, its
non-appearance certainly not against that.

The diagnosis of states of depression may, apart from
the distinctions already discussed, offer difficulties specially
when the possibility of arteriosclerosis has to be taken into
consideration. It may at a time be an accompanying
phenomenon of manic-depressive insanity, but at another
time may even itself engender states of depression.
Especially the physical symptoms of arteriosclerosis, increase
of blood-pressure, tortuosity and rigidity of accessible
vessels, vertigo, paralytic phenomena, aphasic disorders,
will direct attention to this possibility. If already states
of depression or mania have preceded, the causal significance
of the vascular disease will be rejected for the psychic
disorder ; in the other case, however, the decision will be

DIAGNOSIS 199

very difficult. One is thrown back solely on the valuation
of psychic morbid phenomena. Great disorder of memory
and of retention without distinct inhibition of thought,
further, scantiness and uniformity of the delusions, poverty
of thought, emotional barrenness with convulsive weeping
or laughing, weakness of volition and susceptibility to
influence will speak for an arteriosclerotic foundation of the
depression.

The attacks of manic-depressive insanity accompanied
by greater clouding of consciousness and vivid hallucinations
are frequently regarded as amentia.^ The points of view,
which appear to me to be of significance for the delimitation,
have been taken into account in the discussion of amentia.
Schmid - has followed the fortunes of a considerable number
of patients who had presented the picture of acute confusion,
when dementia praecox was thought of, but they had
completely and permanently recovered. He comes to the
conclusion which is certainly right, that just those states of
confusion, even when they present all kinds of " catatonic "
symptoms, represent forms of manic-depressive insanity far
more often than is usually assumed. Many patients of that
kind, especially when the attack runs a rapid course, call
to mind hysterical half-conscious states ; indeed, I have
the impression, that now and then in reality great hysterical
admixture comes into consideration. But, however, flight
of ideas, the merry exultant colouring of the mood, the
great distractibility, and the fearless joy in enterprise are
absent in the purely hysterical states of excitement. This
excitement is connected by preference with definite occasions,
and appears in the form of unlimited outbursts of feeling ;
it discharges itself more in single actions with conscious
aim, in contrast with the permanent, general manic pressure
of activity. Moreover, hysterical excitement after short
duration disappears for the time being rapidly and com-
pletely, while even the slightest forms of manic attack
last far longer and only gradually return to the position of
equilibrium.

Under certain circumstances it may become very difficult
to distinguish an attack of manic-depressive insanity from
a psychogenic state of depression. Several times patients
have been brought to me, whose deep dejection, poverty
of expression, and anxious tension tempt to the assumption

^ Confusional or delirious insanity.

'^ Schmid, Zeitschr. f. d. ges. Neurol, u. Psych, vi. 125,

200 MANIC-DEPRESSIVE INSANITY

of a circular depression, while it came out afterwards, that
they were cases of moodiness, which had for their cause
serious delinquencies and threatened legal proceedings. As
the slighter depressions of manic-depressive insanity, as far
as we are able to make a survey, may wholly resemble the
well-founded moodiness of health, with the essential differ-
ence that they arise without occasion, it will sometimes
not be possible straightway to arrive at a correct inter-
pretation without knowledge of the previous history in
cases of the kind mentioned. At most it may be evident
that the individuals in question are considerably more
constrained and confused at the visits of the physician than
in the interval.

But even when the occasion is known, caution in
judgment is necessary, as, indeed, genuine circular states
of depression also may be occasioned by emotional excite-
ment. Here the circumstance is important that in the
latter case the course of the attack is independent of the
exciting cause. The patients are comparatively little
affected by the further development of affairs, in especial
not relieved even by a favourable turn of events ; they
bring forward delusions, which no longer stand in any
relation whatever to the starting-point of their illness. In
psychogenic depression on the contrary it is seen that every
discussion of the sore point, every piece of news about the
business, calls forth lively emotional storms, further, that
every decision in the uncertainty, and let it be even
unfavourable, generally exercises a reassuring effect. The
judgment may be supported by the appearance of other
psychogenic phenomena, tremors, disorders of gait, fainting
attacks, convulsive laughing and weeping, which certainly
may also occur in manic-depressive insanity, but which
do not present such close relations to the exciting circle of
ideas.

Not altogether infrequently manic patients, occasionally
also inhibited patients, are considered weakminded, even
when otherwise their malady has been correctly diagnosed.
That is specially true of mania with poverty of thought,
which is easily thought to be " imbecility with excitement ".
As already mentioned a judgment of that kind is extremely
deceptive, as long as any distinct symptoms of mania or
depression are still present. I knew a patient who for
months only laughed quietly to herself in an idiotic way,
at most now and then struck her neighbour, and who

DIAGNOSIS 201

was regarded by myself as weakminded ; after her recovery,
however, she appeared unusually clever, cultured, and refined.
Another patient for more than a year made the impression
of a wholly demented individual in consequence of his lack
of understanding and complete incapacity to bring forth a
word ; he gradually came to himself and proved to be
cheerful and lively, though certainly only moderately
endowed. Still another patient was for many months
almost completely mute, and lay in bed apparently without
interest in his surroundings and with a rigid expression of
countenance ; but he obeyed orders, turned somersaults
with a pleased look when desired, and exercised on command ;
later he recovered completely. As soon as the symptoms
of a manic attack are clearly seen, such as indications of
flight of ideas or susceptibility to influence, a merry mood
or occasional jocular actions, the probability of a curable
inhibition of thought will have to be kept in view. Further
the absence of catatonic symptoms will, of course, have
great weight.

CHAPTER XIII.

TREATMENT.

A TREATMENT according to cause of manic-depressive insanity
with its roots deep down in the personaUty does not exist.
Binswanger in one case in which the approach of an attack
appeared to him to be announced by retention of nitrogen
certainly succeeded in aborting it by lessening the supply
of nitrogen, but this experience has hitherto remained
isolated. That a very even tenor of life in protected circum-
stances, especially also with avoidance of alcohol, may have
a certain prophylactic effect with individuals who are liable
to attacks, may be regarded as probable considering the
frequently indubitable influence of external injuries. Also
in the quiet life of institutions attacks are often seen to run a
comparatively mild course.

How far it is possible to suppress in its origin the
individual attack which threatens, we do not yet know.
Kohn has tried such experiments especially for the forms
with short attacks quickly following the one after the other
in which the appearance of a fresh exacerbation can be
more accurately foreseen. He ordered very large doses of
bromides. Twelve to fifteen grams are given daily, if possible
beginning some days before the expected outbreak of the
attack, whose first s5miptoms should be very accurately
noted. It occasionally in fact succeeds in preventing the
appearance of excitement. After the specially dangerous
days are past, the dose of the remedy is very gradually
decreased, and on the approach of the next expected attack
it is again increased to the large quantity mentioned.
Hitzig judging by a few cases has recommended the use
of atropine injections ; the results, however, appear to be
meanwhile rather uncertain.

The appearance of attacks in pregnancy or the puerperium
has now and then led to the attempt by the induction of
artificial abortion to shorten the attack or to prevent its
outbreak. The observations, which I was able to make
with regard to this, were not encouraging. The disease

TREATMENT 203

comes and runs its course as otherwise. Just as little does
a normal confinement as a rule influence the morbid state
favourably ; on the contrary an exacerbation is sometimes
seen. At most, therefore, measures for the prevention of
pregnancy might be considered in the case of women liable
to attacks, but these in themselves are also not altogether
harmless from a psychiatric point of view. On the other
hand we often enough see that quite irregularly in the same
woman in the course of the work of reproduction, at one time
an attack of manic-depressive insanity appears, at another
time not. We, therefore, by no means possess any evidence
at all of the greatness of the danger on a given occasion.

The treatment of manic excitement will be above every-
thing to prevent external stimuli as far as possible. This
indication is met by the placing of the patient in an
institution, which may be dispensed with in very slight forms,
as soon as the limitation of freedom is badly borne and the
malady does not lead to serious injuries and inconveniences.
As we know further that the excitement is always more
increased by activity, we shall limit the pressure of occupation
as far as possible and keep all restless patients in bed, which
especially in physical weakness and bloodlessness is urgently
to be recommended.

In very great excitement the continuous bath is to be
advised instead of bed-treatment. The continuous bath
may here be frankly called the specific means of treatment.
Its beneficent and sedative effect is extremely surprising.
All the other disagreeables so much feared, isolation, dirt,
destruction, violence, can be wholly or at least almost wholly
avoided by this measure. All other hypnotic and sedative
remedies become almost superfluous, if the baths can be
continued during the night also ; otherwise recourse must
now and then be had to paraldehyde, trional, veronal,
luminal, or such things. In cardiac weakness small doses
of caffeine or digitalis are in certain circumstances indicated.
After the excitement has abated, the bath treatment can
be very well combined with temporary stay in the open air.
All injuries and furuncles must from the outset be treated
with the greatest care, as they, especially in corpulent and
very restless patients with weak hearts, may give occasion
for severe infections and thus quickly bring about very serious
danger.

The nourishment of the patients requires special attention ;
it frequently suffers by their restlessness. Abundant, easily

204 MANIC-DEPRESSIVE INSANITY

digested food should be given often, and according to the
circumstances administered with great patience. In more
severe cases daily weighing is to be recommended in order
to judge accurately the condition of the body-weight and in
case of necessity to begin tube-feeding in time.

The psychic treatment of acute mania has, of course, to
take into account the irritabiUty of the patient. Quiet
friendliness, at a suitable moment more a humorous
entering into his cheerful mood, cautious, patient tacking,
do a great deal to facilitate intercourse, and often make the
patient, who in unskilled hands is dangerous and stubborn,
docile and good-natured. When quietness sets in, special
consideration must be given to the avoidance of external
incitements and temptations.

Not inconsiderable difficulties may arise in fixing the
time for discharge, as the patients are often very impatient
and urge to get out in every possible way. But even
patients, who have become quite quiet, may in freedom,
especially under the influence of alcohol, immediately become
excited again and carry out extremely dangerous actions.
The most certain indication for judging the condition is here
also given by the body-weight.

In states of depression bromides are usually employed
with occasional hypnotics, further, evening baths with cold
douching. In greater anxiety opium is given with or without
bromide. The dose is quickly increased from ten up to
thirty or forty drops of the tincture thrice daily. I have not
seen any more benefit from larger doses ; in certain
circumstances they appear to have an exciting effect. After
quietness has set in, the dose is slowly reduced, and, if need
be, again rapidly increased. Besides that there must be re-
membered strengthening nourishment, regulation of digestion,
further, rest in bed with regular stay in the open air.

As the patients are in general mostly excited by those
persons and things which concern them most nearly, by
their relatives, their home, their vocational activity, it will
be desirable, as a rule, to remove them from their accustomed
surroundings. Patients, in whom there is any danger of
suicide, must not in any circumstances be treated in the
family or in a hospital run on the open-door system, but
should be placed unconditionally in a closed hospital under
constant observation by day and by night. An attendant
sleeping in the same room, or worse still in a side-room, is not
sufficient under any circumstances in cases at all serious.

TREATMENT 205

Feeding often causes great difficulty because the patients
resist vigorously on account of lack of appetite or in con-
sequence of delusions ; they do not consider themselves
worthy to eat, they think that they cannot pay, they suspect
poison or nauseating things in the food. Kindly persuasion,
patient waiting for the right moment, careful choice of food,
however, in most cases lead to the goal ; in certain circum-
stances sensible patients abandon their resistance when they
are convinced that otherwise tube-feeding is imminent.

Psychic treatment will have to be essentially limited to
the keeping of emotional stimuli far off. Long conversations,
letters, business arrangements, are, as far as possible, to be
avoided. In cases connected with betrothals personal as
well as written communication with the other partner must
be stopped to begin with, but the final decision for the future
is to be postponed to the time of recovery, if at all possible.

Visits of relatives also may have a very exciting effect,
but I am convinced that their unfavourable influence is
mostly overrated, in as far as it concerns intelHgent people
and only short interviews. Long seclusion of the patients
from their own relatives, as formerly was often considered
necessary, has frequently a very unfavourable effect.
Specific comforting encouragement at the height of the
moodiness is for the most part fairly ineffectual ; later
when the mood is clearing up, the benefit without doubt
often appears greater than it is in reaUty. But still the
consciousness of being able to confide in the physician, and
especially to leave all the little daily decisions in his hands,
is for many patients very reassuring ; also the constantly
repeated assurance that all self-tormenting is morbid and
that there will be complete recovery, is often felt as a comfort
in the thronging of doubts and fears. In slight cases hypnotic
influence may be so far useful in combating unpleasant
sensations, sleeplessness and dejection.

Great caution must be advised in the case of depressed
patients with regard to discharge from the protection of the
institution, as just in convalescence the danger of suicide
is often especially great. Frequently considerable difficulties
arise here by the impulsive home-sickness, which develops
in the patients, and causes the relatives to carry through
the discharge against all the warnings of the physician.
Sudden, very considerable exacerbations, indeed suicidal
attempts, are often enough the consequence. " I immedi-
ately regretted everything," declared one of these patients.

2o6 MANIC-DEPRESSIVE INSANITY

Many patients also wish to leave the institution only on
that account, in order to be able to accomplish their suicidal
intentions outside. In such cases they often manage to
conceal their real mood with great skill from the physician
and from their relatives. Only when the impatient urging
disappears, and perfect insight with a calm quiet mood
exists, when nourishment has returned to the former standard
and sleep is undisturbed, may recovery be regarded as
complete, and the time ripe for discharge. PIxceptions are
advisable only under specially favourable conditions.

PARANOIA

CHAPTER I.

INTRODUCTION

The history of the conception of paranoia^ is very closely
connected with the whole development of our clincial views
of psychiatry. The term, paranoia, which was used first by
Kahlbaum in 1863 in a special sense, then by von Krafft-
Ebing and Mendel, took the place of the older name
Verrticktheit, which was given to a form of insanity
essentially affecting intellectual activity. According to the
older teaching of Griesinger, which in the main point
assumed a single kind of psychic malady running a regular
course in various stages, Verri'tcktheit was always the issue
of a previous disorder of the emotional life. Each psychosis
was said to begin with a melancholic stage, which might be
followed by a period of manic excitement, then of
Verriicktheit, of confusion and, lastly, of dementia when
recovery did not take place at any point. At that time,
therefore, one spoke exclusively .of a " secondary "
Verriicktheit as the unfortunate issue of a psychic disorder
which had not attained to cure. As, moreover, confusion
was also called " general Verriicktheit," which was conceived
as an extension over the whole psychic life of the disorder

^ Snell, AUgem. Zeitschr. f. Psychiatric, xxii. 368 ; Griesinger, Archiv
f. Psychiatrie, i. 148 ; Sander, ebenda, 387 ; Westphal, Allgem. Zeitschr. f.
Psychiatric, xxxiv. 252 ; MerckUn, Studien iiber primare Verriicktheit,
1879 ; Neurolog. Zentralbl., 1909, 846 ; Amadei e Tonnini, Archivio
italiano per le malattie nervose, 1884, 1,2; Werner, Die Paranoia, 1891 ;
Schiile, Allgem. Zeitschr. f. Psychiatrie, 1. i u. 2 ; Cramer, ebenda, U. 2 ;
Sandberg, ebenda, lii. 619 ; Smith, Journal of Mental Science, 1904, Okt. ;
Pastore, Giornale di psichiatria clinica e tecnica manicomiale, xxxv. 3 ;
Serieux et Capgras, Les folies raisonnantes, 1909 ; L'annee psychologique,
xvii. 251 ; Binet et Simon, ebenda xvi, 215 ; Sommer, Leydens Deutsche
Klinik, 297, 1906 ; Alberti, Note e riviste psichiatria, 1908 ; Wilmanns,
Zentralbl. f. Nervenheilk, 19 10, 204.

2o8 PARANOIA

originally more limited, the systematized delusion restricted
to a few parts of the psychic life was contrasted with that as
" partial Verriicktheit."

It was first the investigations of Snell, Westphal, and
Sander, which in the 'sixties of last century led to a
" primary " manner of development of Verriicktheit being
generally recognized. The effect of this undeniable progress
was that the newly recognized form of disease was as a
primary disease of the intellect placed over against mania
and melancholia, in which were seen the standard disorders
of the emotional life. The emotional reactions occasionally
observed in the former malady were said to arise as
" secondary " phenomena by means of delusions and
hallucinations, just as it was thought that the emergence
of intellectual disorders in the " emotional diseases " could
be derived as a result from the primary cheerful or mournful
temper. It was, therefore, of the greatest significance for
the diagnosis to know in the individual case, whether the
disorders of emotion or those of intellect had been the first
morbid phenomena.

The conception of acute paranoia, first briefly indicated
by Westphal, became of special importance for the further
development of the question of paranoia, with which later
" periodic " paranoia was brought into connection.' By
the displacement of the original conception which only took
into account chronic, incurable states, the delimitation of
the morbid state according to external phenomena became
much facilitated. If the course and issue of the disease
were no longer authoritative, the intellectual disorder, the
appearance of delusions or hallucinations, remained as the
only tangible characteristic of Verriicktheit. Thus it came
about that a series of morbid pictures were now incorporated
with it, which, regarded clinically, possessed nothing what-
soever in common with the original Verriicktheit, as, for
instance, amentia,^ alcoholic insanity, and numerous states
which, without doubt, belong to dementia praecox or to
manic-depressive insanity.

We learn from paralysis, from dementia praecox, and in
a certain sense also, from manic-depressive insanity that a
disease in itself may present acute and chronic forms. Here,

* K6ppen, Neurolog. Zentralbl, xviii. 434 ; Thomsen, Archiv f. Psychi-
atrie, xlv. 803 ; Iv. 3 ; Bdge, ebenda, xliii. 299 ; Kleist. Zeitsch. f. d. ges.
Neurol, u. Psychiatric, v. 366.

'^ Confusional or delirious insanity.

INTRODUCTION 209

however, the acute attacks are everywhere only parts of a
course fundamentally chronic ; on this account the prognosis
with regard to the final state remains in principle the same
for each morbid process. But just this characteristic fails
in application to cases of so-called acute paranoia. The
sifting of the morbid cases corresponding to this picture after
a sufficiently long period of observation, shows undeniably
that from year to year an always larger number of these
belong to wholly different well-known diseases. In any case
the greater number of cases of so-called acute paranoia
display neither a peculiar cause, nor a special course and
issue, nor any other clinical characteristics, which would
permit of their being separated from other states. Person-
ally I even doubt if with more detailed exanimation any
remnant clinically of value remains over of the cases. But
yet if one wishes to retain it, it is in any case more expedient
not to give the name of paranoia to the morbid state, because
by so doing essential characteristics of the forms of this
disease generally recognized are obliterated, the insidious
course, the unfavourable prospects of recovery, the permanent
continuance of the delusions which appear.

There was a time when the number of the paranoiacs
in our mental hospitals had grown to from 70 to 80 per cent,
of all cases. The demonstration of a few delusions or
hallucinations sufficed for clinical characterization. The
starting-point was the conception that each paranoiac had
essentially a delusion mentally worked up, " a system ",
which also was regarded as the foundation of his states of
depression and excitement and also of his morbid actions.
Certainly observation itself showed that in very many cases
nothing really could be demonstrated of a delusional system,
but that only a few meagre, disconnected or confused
delusions were given utterance to. In order to explain
the contradiction between hypothesis and findings, it was
usual to seize upon the assumption, either that the patient
did possess a delusional system but for some reason or other
did not speak about it, or that a system had formerly existed
in his mind, but that, however, it was already " dis-
integrated," In this case it concerned an " old paranoiac ",
who certainly might still be very ygung in years. Further
experience has taught that both assumptions, although they
might be appropriate once in a while in a single case, could
not explain the absence of a systematized delusion in an
enormous number of presumed paranoiacs. Rather it

2IO PARANOIA

became clear that here it concerned morbid states which
according to their essential character, were accompanied,
as a rule, not by systematized delusions, but by incoherent,
contradictory, changing, meagre delusions. According to
the principal point it concerned those forms which we now
gather together under the name of dementia praecox. With
these, perhaps, a few cases also of senile, epileptic, or
syphiHtic disease came into consideration.

But when now for the diagnosis of paranoia one came
back to the demand for a delusion to some extent fixed and
mentally worked up, it was seen that the group of such
cases, still very large, did not at all appear to be clinically
uniform. Above everything the fact stood out that the
development of the disease was usually accompanied by
more or less vivid and extended hallucinations, while in
a smaller number of cases the development of the delusion
permanently, or at least for many years, took place solely
by means of morbid interpretation of actual events or by
pseudo-memories. The attempt was made to rectify this
difference by making a classification into hallucinatory
paranoia and systematized or simple paranoia. Further, it
was seen that many cases, and, indeed, by preference the
forms with vivid hallucinations, displayed the tendency to
relatively rapid transition to states of mental weakness,
which made itself known in the extraordinariness of the
delusions, lack of judgment, incoherence, and emotional
dulness. In contrast to that, other patients were seen,
especially those with purely systematized delusions, who
remained unchanged sometimes for decades without essential
loss of psychic ability.

These experiences of necessity suggested the assumption,
that there would be a difference in the character of the
morbid process corresponding to the difference in the course
and issue. For this reason I decided first to separate off
from the others the forms which develop very insidiously,
and which do not lead to states of pronounced psychic
weakness, as paranoia in the narrower sense. The remainder,
which was far more comprehensive, represented the
" paranoid " disease, a group in itself, still by no means
uniform, but put together of very different component parts.
As the greater number of these consisted of cases, which
in many clinical features, as in course and issue, dis-
played unmistakable points of agreement with dementia
praecox, I thought that I should first, till these questions

INTRODUCTION 211

were further cleared up, incorporate them with that disease
as paranoid forms. But further experience has caused me,
as was formerly explained in detail,^ to separate off a few
smaller groups again from the paranoid forms of dementia
praecox under the name of the paraphrenias, because of the
divergent form of their terminal states.

Consideration of the causes and of the history of the
development of paranoiac and paranoid diseases teaches
us that in this direction there is very great multiplicity.
Formerly, when morbid states were the principal guide for
the delimitation of diseases, no special weight used to be
laid on this circumstance. It seems to me, however, that
with progressive knowledge of the true causes of insanity,
the dependence of the clinical state on the conditions of its
development becomes more distinct, although our insight
into these circumstances as yet is still lamentably inadequate.
If the attempt is made to classify according to this point
of view, it appears that both among the paranoid and also
among the paranoiac diseases in the sense delimited above,
a certain number of cases is found which certainly, or at
least with the greatest probability, must be traced back to
definite external causes. Here there are on the one hand
many alcoholic and syphilitic psychoses, but also and
especially a series of psychogenic forms of insanity. It is,
therefore, to be recommended, as has been, done in our
discussion, to separate out at the beginning cases of that
kind and to combine them in special groups. We then
have remaining for " true " paranoia, which alone occupies
us at present, only those cases which are developed from
purely internal causes.

Peculiar difficulties arise,^as already indicated, in con-
nection with the placing of querulant delusion. It was held
for long to be the most characteristic form of paranoia.
In it, for example, the following features are distinct, the
systematization of the delusion, its uniformity and stability,
further, the limitation of the morbid process to certain
circles of ideas, the permanent preservation of the psychic
personality, the non-appearance of phenomena of dementia.
These peculiarities of querulant delusion have also served
me as type for the delimitation of the conception of paranoia.
It is, however, unmistakable that in one aspect a striking
difference exists between querulant delusion and forms of

1 Kraepelin, Dementia Prcecox and Paraphrenia. Translation Edinburgh,
Introduction (Oct. 1919).

212 PARANOIA

paranoia otherwise similar in all the directions mentioned.
In the former the delusion is connected with a definite external
occasion, with a real or supposed legal wrong which stirs
the emotions greatly. In this respect it rather resembles
other psychogenic diseases, especially many forms of prison
psychoses and traumatic neuroses. The question will,
therefore, have to be examined whether the relationship
of querulant delusion to the clinical forms named is closer
than to the paranoiac diseases. On the ground of the
experiences before me, I thought that I must answer this
question in the affirmative, and on that account I have
placed querulant delusion, which formerly was regarded as
a sub-form of paranoia, in the group of the psychogenic
psychoses, in the neighbourhood of those other morbid forms
which likewise take on querulant features.

It must, however, be emphasized that this displacement
has only a comparatively subordinate significance. In a
certain sense a psychogenic mode of development may be
ascribed also to paranoia ; in it definite actual experiences
maj^ acquire a decisive influence on the formation of the
delusional system. The difference lies only in this, that
here the real driving powers for the morbid working up of
events are solclv in the patient himself, while in the various
querulants the external occasion furnishes the deciding
factor for the beginning of the illness. It certainly must
be pointed out that in the latter case also a peculiar pre-
disposition must form the general foundation for the
development of querulant phenomena, as even with the
same external conditions only a fraction of the cases take
this direction. The differences in the history of origin of
querulant delusion and paranoia, therefore, run out only in
the direction of a certain displacement of the relations
between external, psychogenic influences and internal morbid
causes. But besides that there is still further the special
idiosyncrasy of the querulant tuned to strife with legal
authority, the development of which by external occasion
is driven into a very definite direction diverging in manifold
ways from the conduct of the paranoiac.

If with the help of these explanations the attempt is
made to define the conception of paranoia, as it forms the
foundation of the following exposition, stress would be laid
on this feature of it, the insidious development of a permanent
and unshakable delusional system resulting from internal
causes, which is accompanied by perfect preservation of clear

INTRODUCTION 213

and orderly thinking, willing, and acting. At the same time
that deep-reaching transformation of the whole view of life
that " Verriickimg " of the standpoint in regard to the world
around, is usually accomplished, which was characterized by
the name " Verrucktheit ".

The development of the morbid conception here discussed
has been essentially different in French psychiatry. While
in Germany it concerned principally questions of separating
and grouping mental disorders, the French investigators
made far more effort to describe isolated clinical forms in
the most vivid wa}^ possible. The manifold content of the
delusions, of the " delire ", was taken into account, its origin
from hallucinations or delusional interpretations, " inter-
pretations delirantes,''. its elaboration (delire systematise),
the general psychic state of the patients (" folie lucide,
raisonnante "). The works of Falret and Lasegue were of
special significance for the question discussed here. The
former described the progressive development of the
delusional formation, from the preliminary period to that
of systematic building up, and lastly the monotonous
fixation of the delusion, and so characterized a peculiarity
of the course which we often find in true paranoia, but
also in dementia paranoides and in paraphrenic disease.
Lasegue described the morbid picture of the persecuted
persecutors, of the " persecuteurs persecutes," which includes,
namely, the querulants, but also other forms of the delusion
of persecution in which the patients finally proceed to
dangerous attacks on their supposed enemies.

From an essentially different standpoint Magnan came
nearer to the solution of the question of paranoia. His
clinical views are dominated by the endeavour to separate
the mental disorders of the degenerate from the forms
arising on a healthy foundation. The characteristic paranoid
disease of the last group is " delire chronique a evolution
systematique," already discussed by us, while to the first
belong the persecuted persecutors and the querulants, and
also those delusional morbid forms which are more or less
remote from the type of " delire chronique " by reason of
their " atypical " formation, by suddenness of development,
combination of delusions of different kinds, and divergencies
in the course. Jf the ground of classification which was
authoritative for Magnan can scarcely any longer at present
be regarded as justified, yet his classification, which to a
certain degree separated the querulants and true paranoiacs

214 PARANOIA

from other paranoid diseases, signified a decided step in
advance.

The latest development of French psychiatry has brought
conceptions of the doctrine of paranoia, which, notwith-
standing many differences in detail, yet move pretty much
in the same paths as the discussion attempted here. Regis
has postulated a " psychose systematisee progressive "
which with its chronic development of a delusional system
without hallucinations might correspond in the main to
" true " paranoia. Serieux, who has written a great deal
about these questions, separates sharply from each other
the " delire d'interpretation " and the " dehre de revendi-
cation " ; the former corresponds accurately to our
paranoia, the latter to quenilant delusion. That I consider
this separation well-founded, and why I do so has been
already explained. Finally, various investigators, especially
Dupre, have described a " dehre d'imagination," in which
pure imaginations, relatively pseudo-memories, without
connection with real perceptions, are said to be the driving
power of the delusion formation. Neisser also has spoken
of a " confabulating paranoia." If I disregard confabulating
paraphrenia^ already described, it seems to me that no
genuine paranoiac state can be separated off from the
point of view mentioned. Certainly fantastic inventions
and pseudo-memories frequently play a considerable part
in the history of origin of the delusion, but yet always only
along with other delusional occurrences. When the former
exclusively dominate the condition, it might rather concern
morbid liars and swindlers, " mythomanics " according to
Dupres.

' Dementia Prescox and Paraphrenia, p. 309.

CHAPTER II.

GENERAL MORBID SYMPTOMS.

The morbid picture of paranoia is comparatively poor in
detail, as the more striking disorders only extend over
limited domains of the psychic life, and leave others wholly
untouched or nearly so. Observation and perception in
general proceed without hindrance, although the impressions
are often morbidly interpreted. The patients remain
permanently sensible, clear, and reasonable. Genuine
hallucinations do not occur, as according to more recent
experience and in agreement with Serieux I must assume.
In one of my cases, in which after the disease had lasted
for many years numerous hallucinations of hearing were
developed, it turned out later that syphilitic brain disease
probably existed.

Visions. — On the other hand the patients not in-
frequently tell of isolated or fairly frequent visionary
experiences, which are mostly referred to the night-time,
but occasionally also are said to have appeared during the
day on any special occasion. They see stars, shining figures,
divine apparitions. It is possible that here it frequently
concerns states of dreamy ecstasy. In other cases natural
occurrences are misinterpreted ; in the full moon God the
Father becomes visible ; a cloud takes on the form of an
apocal5/ptic animal. But sometimes the descriptions given
by the patients, which are mostly connected with events
which took place long ago, arouse the suspicion of pseudo-
memories ; thus a female patient alleged that at the age
of four she saw heaven opened. Sometimes on these
occasions the patients also receive orders or assurances
from God ; the blessing of Esau was given to a patient
on the left shoulder, the blessing of Jacob on the right.
Others are threatened by the devil, strangled, endure
conflicts. Such experiences are always regarded by the
patients as supernatural events which do not belong to
ordinary experience. A few patients also perhaps assert
that they are in constant communication with God, that
they receive inspiration from him, but there it never is a

2i6 PARANOIA

case of real hallucinations of hearing, but always only of
the emergence of exhorting, warning, assuring thoughts,
which in the manner of the " voice of conscience " are
traced back to supersensual influences.

Memory and Retention show no disorder in domains
lying outside of the delusion. Pseudo-memories are, however,
extremely frequent ; they usually stand in the closest
relation to the morbid circle of ideas. Sometimes it is
only a wrong valuation and a transformation of experiences
subsequent to their occurrence, sometimes it is the emergence
of wholly invented utterances or events in the form of
memory pictures. The patient reports communications,
which have been made to him in a mysterious way, meetings,
which he has had with prominent people, strange attacks,
to which he was exposed. The blind imphcit confidence
is always very remarkable in these cases, which is given
to the alleged utterances of any individuals whatsoever
about the most important secrets. Often very complicated
experiences are narrated with all details. The jealous man
saw and heard his wife misdemean herself in the most
shameless way with his rival ; a shot fell on the patient
which tore off his hat and stretched him on the ground ;
at the same time someone appeared with a knife in order to
mangle his face past recognition.

Sometimes one can trace directly how such memories
emerge in the patient and become fixed. Some patients
allege that they already knew beforehand of the occurrence
of this or that event, thus of their being brought to the
asylum ; it has all of a sudden occurred to them again. One
patient said that everything that he had thought to himself
had come true already before this ; others assert that they
can prophesy. The extraordinariness and undisguised
improbabihty of the proffered narratives often makes it
easy to recognize them as pseudo-memories. Here belong
the statements of those, who are expecting thrones, about
the information which was given to them already in their
youth about their birth and about their claims.

In other cases when the patients with absolute conviction
report observations which are within the limits of the possible
or even of the probable, it may become extraordinarily
difficult to discover the morbid history of origin of the
pseudo-memories. Thus in delusions of jealousy one is
often in doubt how far real occurrences or delusional
inventions are the foundation of what the patients say

GENERAL MORBID SYMPTOMS 217

about the alleged suspicious observations, indeed about
the apparent admissions of the husband. Apart from
general grounds of probability, the latter assumption
will be justified if the patients adorn their narrative with
very exact details always increasing on repetition, when they
only produce their alleged observations a long time after
the event, and also when their conduct at the time of the
events and after has not in the least corresponded with what
would have been expected in reality.

In my opinion, the part played in paranoia by pseudo-
memories has often been underestimated. The statement
is not infrequently found that the delusions in such cases
may go back to early childhood, a circumstance which has
been regarded as a strong argument in favour of the origin
of the malady being a morbid disposition. Although the
correctness of this view may be acknowledged without
reserve, I yet consider that its substantiation by the state-
ments of the patients about delusional experiences in child-
hood is not sound. Obviously these are the expression of
pseudo-memories just as the corresponding narrations are in
dementia praecox and paraphrenia.

Delusions of Reference. — In a still far higher degree
than the picture of the past, the psychic appreciation of
present experiences is influenced by the delusional processes.
The disorder here dominating the morbid state can, perhaps,
best be characterized by the expression dehisions of reference.
Numerous impressions and occurrences are not accepted in
their sober every-day character, but they enter into some or
other relation to the patient's own fortunes and misfortunes.
Above everything the doings of his fellow human beings suffer
this prejudiced interpretation.

The demeanour and the glances of the passers-by, a
movement of the hand, a shrug of the shoulders, have a
mysterious meaning for the patients ; it is sometimes painful
and tormenting, sometimes elevating and beneficent. People
wish in that way to insult him, blame him, make him
contemptible, warn him, encourage him, impart to him
some or other important information. A phrase accident-
ally caught up, a remark at the neighbouring table contains
a hidden allusion ; it is " the customary picture-language " ;
" They thought that I did not understand it," said a patient.
The conversation of the party at table points dimly to a
secret understanding ; the patient " notices that there is
something there, but doesn't know what it is."

2i8 PARANOIA

The same phrases are done to death with obvious
intention on quite definite occasions. Certain songs are
whistled in a remarkable manner in order to point out
trivial occurrences in the patient's past, to give him hints
for his work. In plays, in the most recent novel, in the
newspapers there are references to his doings ; the clergy-
man in the pulpit, a stump orator makes allusions to his
person which cannot be misunderstood. It suddenly comes
about that he continually meets the same people, who
apparently watch him, and follow him as though by chance ;
people stare at him, clear their throats, cough on his account,
spit in front of him or avoid him. In public restaurants
people edge away from him or stand up as soon as he appears,
look at him with stolen glances and criticise him. Cabmen,
railway guards, workmen talk about him. Everywhere
attention is directed towards him ; his clothes in spite of
their strangeness are copied by numerous unknown people.
Isolated remarks which he has let fall immediately become
public catchwords. One of my patients had called yellow
the colour of the intellect ; the next day everyone was
wearing yellow roses, as the rose is the symbol of silence
in order to indicate to him that he was clever and should be
silent. " Who will reckon up everything that speaks to me
here ! "

All these experiences are in themselves of wholly
indifferent content ; they appear " quite natural to every
one who is not initiated," as chance accidents, but the
patient perceives only too distinctly that everything is
" arranged " with consummate cunning, that it is a case of
" the artificial production of chances," behind which a base
conspiracy, an important state affair is concealed. Certainly
the whole game is extremely cleverly managed in order to
deceive him or in order not to disclose great plans for the
future prematurely. As often as he asks anyone to explain
frankly, giving him to understand that he sees through
everything, the person assumes an innocent air and invents
all kinds of subterfuges ; people do not steer straight to
the goal but by round-about ways, while the real aims are
only alluded to in veiled indications. People cone to meet
him with a friendly manner in order to deceive his vigilance,
entangle him in peculiar conversations, misrepresent the
facts to him with mental reservation ; the true meaning of
this he certainly understands at once.

The following passage from the diary of a patient, who

GENERAL MORBID SYMPTOMS 219

believed that he was aimed at by a secret league for the
furtherance of pederasty, gives perhaps an idea of the very
peculiar displacement which is accomplished in the relation
of the patient to the external world : —

" That a confederacy with aims, such as are evident from these lines,
makes every effort that these aims should not become public and therefore
tries to make propaganda in hidden or symbolic form, is enlightening. As
it now cannot be certain what attitude the individual influenced by it will
assume with regard to the matter, it tries by all kinds of ingenious devices
running parallel, as it were, with the main effort but in themselves innocent,
to confuse him, relatively to protect itself from unpleasant disclosures.
Thus, e.g. I had at that time got into the habit, as is indeed the case with
almost everyone, of using a few stereotyped phrases, among others,
" Certainly ! " and " Scarcely to be believed," and lo and behold !
I found these two sentences and many others as well in rapid sequence, as
heading to an advertisement in large letters in the Generalanzeiger . From
that I could of course only conclude that chance and my life are thus day by
day composed of nothing but chances, so that it would finally have become
the purest fantastic double life. — That, however, is scarcely to be
believed ! — "

Internal connections between two events following each
other by chance are very frequently assumed. A patient
laid before the prime minister of Baden a map, on which
the regions of the world not yet occupied were marked ;
immediately afterwards the German colonial policy began.

Sometimes also natural occurrences acquire a special
significance for the patient. The peculiar twinkling of the
stars, the changes of weather, the flight of birds, the sovmd
of bells, symbolize in some or other way events in the life
of the patient or his future. They terrify him or encourage
him ; they contain threats or promises. Usually it concerns
isolated occurrences which find the patient in a peculiarly
susceptible mood. Here there are points of contact with
ordinary superstition, which likewise ascribes to chance
occurrences in the external world profound relations to the
individual's own fate ; one need only think of the motives
which may cause any one to try his luck in the lottery with
just this or that number.

Delusional interpretations lead occasionally to peculiar
mistakes about people in which external resemblances play
no part at all. An officer riding past is the sovereign or at
least his adjutant who thus wishes to give the patient a
sign ; a lady in a carriage is a princess who is trying to come
into relations with him. His persecutors, who emerge
everywhere, are at once infallibly recognized again by the
patient in spite of their disguises and external changes ; the
mysterious loved one may also in certain circumstances
assume the most manifold forms.

220 PARANOIA

As the common source of pseudo-memories and of delusional
interpretations we may well regard the tendency to morbid
imaginings, as it has been described by Dupre and Logre^
as " delire d'imagination." Series of presentations appear
before the mental vision of the patients, sometimes a net of
secret machinations, in whose meshes they are hopelessly
entangled, sometimes delightful hopes for the future, to the
fulfilment of which they look forward with confidence.

Uneasy forebodings may thrust themselves also on a
healthy individual with or without external occasion ; he
may build castles in the air, occupy himself with the
picturing of alluring possibilities of good fortune, and accept
with satisfaction tokens of coming bliss. But while he
always remains conscious of the unreality of his play of
imagination and rectifies it by deliberation, it appears to
the patient as the trustworthy expression of reality. It
acquires an authoritative infi\ience on the whole of his
thought and activity and instead of being driven away by
reflection and experience, it convincingl}'^ transforms
treasures of memory, the mental working up of events of
life, and the view of the universe.

The mental disorder which dominates the morbid picture
of paranoia can, therefore, be characterized in two directions.
In the first place the whole system of thought bears a
morbidly personal stamp. The patient is the centre of a
surrounding area which in the most multifarious way occupies
itself only with him and his fort\mes ; what happens in his
neighbourhood is not indifferent or casual, but has a profound
relation to himself. But further, he lacks the capabiUty to
measure the products of his powers of imagination with the
scale of sober experience. For him they have that
immediate certainty of belief which leaves no room at all for
doubt.

Delusion Formation. — The results of these disorders
is the delusion fonnation peculiar to paranoia which may
develop in the two fundamental directions of ideas of injury
and of exaltation. The delusion here usually matures very
slowly, taking many years. At first it remains within the
limits of suspicious conjectures, arrogant and overweening
self-conceit, secret hopes ; but these draw ever fresh nourish-
ment from the prejudiced evaluation of the experiences of
life, and they become more and more fixed. Occasionally
under the influence of particular conditions or internal

' Dupr6 et Logre, L'Enc^phale, 191 1, 209,

GENERAL MORBID SYMPTOMS 221

states, it appears that the delusion progresses more by
exacerbations, unless the descriptions of the patients about
such occurrences are coloured by pseudo-memories. On
some or other occasion scales seem to fall from their eyes,
secret connections become clear to them like lightning ;
the present and the future are disclosed to them by
inspiration. At other times the delusion formation may
apparently stand still for many years ; the same ideas, at
most decorated by a few pseudo-memories, are produced
unchanged without being enriched by fresh delusional
experiences.

The delusion of the paranoiac is invariably " system-
atized," mentally worked up, and uniformly connected,
without gross internal contradictions. The patients exert
themselves to gain a picture, certainly distorted in an
extremely ego-centric fashion, of their place in the
mechanism of life, a kind of view of the universe. They
bring their experiences into relation with each other, they
search for cause and effect, for motives and connections.
Obscure points and contradictions are as far as possible
set aside and smoothed over by laborious thought, so that
a delusional structure arises, which, however, with all the
improbability and uncertainty of its foundations, does not
usually contain any apparent absolute impossibilities. The
patients will even listen to objections up to a certain point.
They can at once refute them, it is true, by pointing out
their special internal and external experiences, but yet, at
least, they acknowledge the necessit}^ of substantiating their
assertions and of defending them against doubts.

It is exactly this internal working up of the delusion
which leads to its becoming a component part of the psychic
personality, to its passing into the flesh and blood of
the patients. With this is connected its irrefutability.
Although the patients themselves, perhaps, admit that
they seldom or never can produce a really convincing proof
of the correctness of their view, yet every attempt to convict
them of the delusional character of their ideas rebounds as
from a wall. At most they allow that the recognition of
the inner connection of all the apparent chance circumstances
can only be acquired from the standpoint of that personal
conviction, " which just irrefutably has existed and will
exist," as a patient said. " I live in the imagination that
that is no imagination." The patient, therefore, feels
occasionally that an uninitiated cannot follow his trains

222 PARANOIA

of thought everywhere, and so fears that his persecutors
might make use of this state of affairs in order to assert that
he is afflicted with the delusion of persecution. Of morbid
insight there is never any question. A patient, indeed, said
that he now knew himself that he was mentally ill, for

" so long as a human being knows that he is still separated from the
holy and living God, his creator and preserver, still through sin and guilt or
his own inner evil spirit, which lives by devouring and drinking, thus knows
that he is not yet one with God, in spirit and in his conscience, therefore
does not yet feel justified by the Holy Ghost, it is self-evident that he must
feel himself mentally ill."

That is, of course, no morbid insight, but a paranoid
interpretation of a concept, behind which the assumption
of a peculiarly strict and orthodox apprehension of the
relation to God is distinctly recognizable. The patient
then added further, " To the holy triune God all men are
mentally ill."

The fundamental unchangeableness of the delusions is
considered with a certain amount of right to be a chief
characteristic of paranoia. Only very recently doubts have
arisen whether a too literal acceptance of this pronounce-
ment corresponds with experience. On the one hand " mild
forms of paranoia " have been described by Friedmann ^ ;
in these after a few years the delusion gradually recedes
again. On the other hand Gaupp has called attention to
cases of " abortive paranoia," in which, under the influence
of unpleasant conditions of life, less rigid delusional systems
are developed, which without actual rectification may gradu-
ally be obliterated. We shall later have to examine how
far it appears feasible to place these cases within the morbid
conception of paranoia. It must, however, also be taken
into account that the absence of susceptibiUty to influence
of the paranoiac delusion can scarcely be present at the
beginning. Rather must we assume that in the many years
of preparation the delusion grows only very gradually, that
the patients offer resistance to the suppositions which are
thrust upon them, rejecting them at first, and then after
many inward struggles they are finally overpowered. The
possibility can, therefore, scarcely be contested on principle
that the development of the malady does not progress
through such a period of [preparation with fluctuating
delusions.

Mood corresponds throughout to the content of the
delusions brought forward. Many patients are shy,

' Friedmann, MonatssChr. f. Psychiatric u Neurol., xvii. 467.

GENERAL MORBID SYMPTOMS 223

suspicious, dejected, irritated, others self-conscious and
confident. Frequently, there is in general no conspicuous
colouring of mood at all recognizable, but it perhaps appears
more distinctly when the delusional ideas are discussed.
Great fluctuations of emotional equilibrium do not belong
to the morbid picture, as I should like to emphasize in
opposition to the statements of Specht. Nevertheless one
may assume with Bleuler^ and Specht that in the history
of origin of paranoiac delusion emotional tension play? a
considerable part, although I consider that Bleuler's tendency
to regard definite " complexes emphasized by affect " as the
starting-point of paranoid delusion formation, goes too far.
The two opposed directions of the delusions which are often
associated with each other appear, however, to point to a
close relation with emotions ; we have to do with, as Maier -
has expressed it, " katathymic " delusion formations. Their
content shows, although in a morbidly developed form, such
a remarkable agreement with those fears, wishes, and hopes,
which even in normal individuals proceed from the feeling
of uncertainty and the endeavour after happiness, that one
is tempted to believe in a similar foundation here. On the
one side we find the fear to be despised and mocked,
threatened by a systematic persecution, deceived in wedlock,
on the other side the dehghtful conviction of being of
aristocratic descent, the favourite of a highly-placed person-
age, inventor and benefactor of the people, the chosen of God.
Activity and Conduct often remain without any very
definite disorder. The patients are mostly able even to
earn their hving permanently without being specially
conspicuous in their surroundings. Certainly all kinds of
peculiarities frequently appear in the conduct of their lives.
A patient expressed himself as far as possible only in writing,
because he had need of quiet and of communion with God ;
he often fasted for several days and he gave the following
explanation of this : —

" Fasting and prayer do not weaken men at all, but just the opposite ;
they strengthen the spirit, purify the heart, and make a man free from his
sinful nature."

Many patients withdraw themselves, bur}^ themselves in
books, compose comprehensive documents ; others wander

' Bleuler, AfEektivitat, Suggestibilitat, Paranoia, 1906 ; Specht, Uber
den pathologischen Affekt in der chronischen Paranoia, 1901 ; Zentralbl. f.
Nervenheilk. u. Psychiatrie, 1908, 817.

2 Maier, Zeitschr. f. d. ges. Neurol, u. Psychiatrie, xiii. 555.

224 PARANOIA

about restlessly, change their situations frequently, make
their appearance sometimes at one place, sometimes at
another. There is little inclination for regular and con-
tinuous employment. A merchant, who had gained a small
competence in America and had returned home ill, spent
his money little by little till he fell into the hands of the
Guardians, as he was too proud to undertake work not suited
to his high valuation of himself. Now for the first time it
came out that for almost twenty years he had suffered from
pronounced ideas of persecution and exaltation. Often the
patients, in spite of good abilities, do not accompUsh anything
rightly, but are always unsuccessful ; they spend far more
than their circumstances allow, busy themselves with the
most difficult problems, without sufficient understanding and
without knowledge. Nevertheless they not infrequently are
capable of exercising an important influence on their
surroundings, of procuring for themselves a certain amount
of consideration, of convincing some people of the correctness
of their delusions, and possibly also of turning them into
enthusiastic adherents, as we have described more in detail in
the section about induced insanity.

The patients invariably come into contact with the
alienist only late, if at all, and even then for the most part
only temporarily, if they have made themselves conspicuous
or given offence by any action in line with, their delusion.
They usually possess so much self-mastery that they
habitually avoid all conflict with law and authority. Besides
that they are never so tormented that they would be driven
to regardless deeds of violence by overpowering inward
tension. It, therefore, for the most part does not go further
than comparatively harmless actions, abusive language,
threats, advertisements in the newspapers, complaints to
the police, attempts to force an entrance to highly-placed
persons, unreasonable religious practices, the exploiting of
people on the ground of delusional claims. Now and then,
perhaps, a suicidal attempt may occur.

Bodily Symptoms. — In the bodily domain no tangible
divergence from normal exists ; appetite and sleep are as
a rule not disordered. Many patients bring forward all
kinds of hypochondriacal complaints, they complain of
nervousness, oppression in their head, digestive weakness,
for which the medical treatment is readily held responsible.
They then, perhaps, take refuge in all kinds of singular
cures, some of them self-invented.

CHAPTER III.

CLINICAL FORMS.

The clinical classification of paranoiac states offers peculiar
difficulties because, as it has been well expressed, there are
as many forms as there are individual patients. In fact
here personal peculiarity , which is relatively little affected
by the malady, exercises a far-reaching influence on the
configuration of the morbid phenomena. The multiplicity
of individual features will, therefore, be much greater than,
say, in the grossly destructive morbid processes of paralysis
or even of dementia praicox. Nevertheless, at least, certain
general trends of delusion formation are repeated so
invariably, that they may well serve as starting-point for
a division of the material observed into some smaller sub-
groups. Here we shall perhaps best begin with separating
the morbid states with predominating delusions of injury
and those with ideas of exaltation ; in both directions some
other special kinds will then be distinguished.

Delusions of Persecution. — ^This is the most frequent
form of paranoia. The patient, who already for a long time
has perhaps felt himself neglected, unjustly treated,
oppressed, not sufficiently valued, makes the observation,
that on some or other occasion people no longer greet him
in such a friendly way as formerly, that people are now
more reserved towards him, and avoid him, and, in spite
of many, as he says, hypocritical proofs of friendship, will
have nothing more to do with him. In consequence of
this his irritability and his distrust increase ; he begins to
notice the behaviour of the people round him, and gradually
finds numerous indications that people are systematically
planning to injure him^ in every way, to undermine his
position, to make him impossible. " I read everyone's
thoughts from his face and I have good hearing," declared
a patient. He is watched and spied on, detectives are sent
after him, whose duty it is to keep their eye on him and
collect material against him. On the street he has a feeling
as if he must run the gauntlet. People look at him

226 PARANOIA

contemptuously, whistle and laugh behind his back,
challenge him, try to irritate him. Harmless remarks are
full of concealed malice ; certainly people do not speak
out, they say nothing definite. In the " Fliegende
Blatter " there is offensive abuse ; everywhere there is
hounding and backbiting, jeering and chicanery. " It is
all hes and deceit, hypocrisj'^ ; I don't trust anyone any
longer ; no one wishes me well," said a patient. He is
treated in the most insulting wa}^ people ape his voice,
call him by nicknames, whistle to him as to a dog, throw
snowballs and stones at him. It is a concerted game ;
all blow the same horn ; " Manus manum lavat," said a
patient. Now and then the delusion is also supported by
pseudo-memories ; the doctors had allowed she was quite
right in her ideas, declared a female patient.

The kind and the range of the continual chicanery are
very multifarious. The lodgers give false names, do not
pa}^ put beer-bottles before the door, throw them on to
the street in order that people may think that the patient
is a drinker. Letters directed to him are opened and read,
purloined ; a female patient received at the instigation of
her opponent a forged denial from the district court.
Consignments for customers are spoiled and rendered dirty,
so that complaints constantly come in. The chimney of
the stove is stopped up, boots are damaged, suits and under-
clothing are ruined. In lawsuits hostile machinations are
instigated, so that they will be lost ; the lawyers are bribed ;
financial intrigues, swindling and fraud are going on ; the
tenant is being incited to pay no rent any more. Calumnies
are scattered abroad about the patient as if he had brought
on himself a nervous disease by debauchery, as if he were
syphiHtic, or addicted to pederasty. His photograph has
been sent to brothels in order to represent him as an habitue
there. Forged bills were made pubhc as if he daily took
a senseless amount of alcohol. By such means he is driven
from his situations, he is ruined, he loses his inheritance,
and, finally, people plan to seduce him to sexual outrages,
to onanism, to make him go mad, or even to make away
with him altogether. The physicians are bribed, give
doubtful medicines ; there is poison in the beer ; the taste of
the food is extremely suspicious and causes colic, dizziness and
noises in the ears. " I know very well what that is," declared
a patient. His neighbour at table fell ill, after he had by
accident drunk from the glass destined for the patient.

CLINICAL FORMS 227

Thus the circle of persecutors is gradually extended
further and further. If the patient changes his place of
residence, he has peace at first perhaps for some time, but
he very soon notices that people meet him as a personage
who has already been announced, and they have complete
information about him and the whole of his previous life.
In all sorts of indications secret threads are spun from his
former to his present surroundings. People spy after him
everywhere ; some individuals whom, in spite of supposed
disguise, false beards, dyed hair, he recognizes everywhere
again, follow his every step, so that his position is often
" worse than that of a man pursued by a warrant of arrest " ;
it is a " boycott and a vehmgericht."

In connection with observations of this kind the patient
usually has extremely remarkable ideas about the originators
and the extent of the persecutions directed against him.
A definite person is sometimes regarded as the real driving
force, a faithless lover, a former fiancee, a sister-in-law, a
colleague, the mayor. Or the freemasons, the social
democrats, some or other secret society is behind it all.
Of course, they have at their disposal enormous means
and resources, everywhere they have aiders and abettors ;
not only all possible private persons, but also officials,
courts, police, clergymen, physicians, journalists, authors,
have a share in the general conspiracy.

The following extracts from a letter written by a female
patient afford a glimpse into this circle of ideas : —

" During the fourteen years that I have hved here, I have led the hfe
of a martyr which mocks at all comparison. It concerns the embezzlement
of inherited mone)', and on account of this all imaginable evil and cunning
was exercised, that I might be passed off as insane and so on, or that I should
be made so, and that the necessary means of living, credit and honour
should be taken from me. This inexcusable behaviour by day and by
night is carried on by the secret police and their aiders and abettors, female
and male, young or old, poor or rich^ — all must assist ; since it is for the
police ! The hounding was ordered in all houses and districts of the town
and no regard was had for an old widow full of years. Since I came to
Munich, all my letters have been kept back, opened, and delivered without
a stamp. Letters about inheritance were simply suppressed, so that I
never could be present at the distribution like the other heirs. Every
effort is made that I may not be seen and that I should not come into
contact with anyone ; indeed it is horrible and incredible that such abomin-
able occurrences can happen, carried out by certain lawyers, who have
embezzled my money ; of course they have also a certain police jurisdiction
at hand, which facilitates for them their infernal ongoings in order that it
should not come to light ; besides they are rich, with which one can close
the mouth of many a crime . . . When I arrived in Munich I found my
house in the greatest disorder, although, before I left hoAe, I left every-
thing punctiliously in order. The furniture was covered with a layer of

228 PARANOIA

dirt and dust, the bed-clothes were thrown about anyhow, every drawer
and cupboard was opened, although I had carefully locked up everything,
closed the box of keys and taken it with me ; in the kitchen the pretty
mirror was in fragments. It went so far that I was forced to hesitate about
eating anything, for after these rascally tricks people are capable of any-
thing, whatever can be conceived horrible and mean ..."

Along with the delusions of persecution other delusions
of all kinds, which come less into the foreground, invariably
appear. We frequently find hypochondriacal fears. The
patient notices that his memory is giving way, he is afraid
of softening of the brain ; he complains of pains in his
head and back, oppression in his chest, cramp in his stomach,
spitting of blood ; his health is seriously injured, his whole
body is done for. Now and then ideas of jealousy are present.
But on the other hand an exalted self-consciousness frequently
exists. The patient is very religious, cleverer than all
other people, understands everything better, gets through
" literally the double " amount of work, wanted to be
something really great, to be respected, honoured, to take
a higher position, A female patient had the conviction
that " money must be hanging somewhere." Others assert
that they must demand large sums as compensation, as
inheritance, from the father of their illegitimate child.

Mood is for the most part excited, irritated, and em-
bittered. " For me the sun has not shone and will never
shine," declared a patient, " life is abominable ; for me it
remains empty of love. Men are wicked ; already in the
child there is malice and guile, scorn and derision ! Why
do people continually speak about me and spit in front of
me ? People cannot look at me and will not look at me —
that is how it is,"

The patient, of course, tries in every way to withdraw
himself from the persecutions, changes his place of residence
and situation, brings actions for damages, provides himself
with weapons and dogs for his protection. He addresses
querulant petitions to the authorities, the ministers, to
Grand Duke and Kaiser, in which he generally makes use
of very violent language, speaks of " beastly government
and a brigand state," demands the removal and punish-
ment of his opponents and makes claims for compensation.
Further, he tries to stigmatize the infamous game of his
enemies publicly by means of the newspapers or by broad-
sheets and to defend himself against the concealed charges.
He also, perhaps, sets about doing something conspicuous
in order to direct general attention to his endangered

CLINICAL FORMS 229

position, causes a street riot, throws a petition among the
assembled representatives in parHament, or tries to force
his way to the reigning Prince. Some patients make
suicidal attempts ; others publicly ask their supposed
antagonists to explain, abuse them, threaten them with
violence, so that the interference of the police becomes
necessary. In certain circumstances, as the morbid founda-
tion of his procedure is not always easily recognizable,
measures follow next, which still further embitter the
patient. " x\t first a fellow like that plagues a diligent
and capable man for years, and if this latter, reduced to
extremity and without prospect of help, takes to self-defence,
then — punishment, severe punishment ! " wrote a patient.

As the patients, apart from the activities mentioned
proceeding from their delusions, always behave in an orderly
way and do not usually commit really serious acts of violence,
they do not, as a rule, lose their freedom more than
temporarily. In their behaviour they are sometimes
passionate, vivacious, talkative, clever, sometimes reserved,
morose, repellent. They hold firmly and resolutely to their
delusions, although at times they do not speak about them
at all. " He wished to remain the evil conscience of his
opponent," declared a patient. Only after the morbid
phenomena have lasted for decades, does the internal tension
perhaps yield and with it the vividness of the delusions,
without, however, a rectification of the paranoiac view of
life taking place.

Delusions of Jealousy ^ — This is in many respects
related to the form just described. The patient is very
gradually seized by the suspicion that his wife is deceiving
him and he now notices all kinds of things which strengthen
him always more in the idea. His wife appears to him
colder ; she rejects advances, she quarrels and scolds ;
she goes out whenever she likes to the restaurant and to the
theatre, visits a relative or a neighbour extremely often
even at an unusual hour and remains an excessively long
time. When she returns home, she is embarrassed, makes
all sorts of evasive excuses. People make allusions, speak
in a mysterious way, so that his suspicions cannot but be
aroused ; there are " spiritual proofs." " There are many
things which taken together make a complete chain of
proof," declared a patient. Another, who thought that his
brother was his rival in love, got pains on cohabitation,

^ Jaspers, Zeitschr. f. d. ges. Neurol, u. Psychiatrie, i., 567.

230 PARANOIA

when his brother was infected ; "I can explain the whole
train of thought to myself," he said.

A considerable role is often played here by pseudo-
memories. The patient reports serious charges made by
his wife and confessions which she has made to him. He
remembers that all sorts of suspicious men came to the
house, who under various pretexts asked for his wife and
had nothing to say when they only found him. Occasionally
afterwards it becomes clear to him that these were the very
people whom he was now suspecting, that they, therefore,
had obviously had relations with his wife for a long time
already. A patient narrated with all detail how his wife
had repeatedly shut herself up with her lover in the water-
closet. He then wanted to search out the latter quickly
and he threatened to force open the locked door ; on this
the lover then slipped out quickly making no noise, an
occurrence which happened again in exactly the same way
a few weeks later. Once also he saw through the sitting-
room door how his brother-in-law used his wife from behind.
Another patient, described by Jaspers and observed also
by myself; noticed how at night a cloth was laid over his
face and his wife in bed beside him accomplished cohabitation
with his rival, how both whispered together and how the
lover then left the house. The too exact description of
what went on, in the first case the similar repetition also,
lastly, the alleged purely expectant behaviour of the patients
in such circumstances make the existence of pseudo-
memories indubitable.

In connection with his delusional experiences the patient
brings forward the most serious accusations against his wife.
She has always led him by the nose, she keeps a whole lot
of lovers for herself, she has intercourse indiscriminately
with hawkers and lodgers. A patient asserted that his
brother continually carried on incest with his mother and
adultery with his wife. Another accused his wife of having
intercourse with her sons ; a female patient stated that her
husband had let himself go with their little daughter since
her earliest childhood. The patient does not acknowledge
his children any longer because they are not his, they do
not resemble him ; he notices in them unmistakable features
of his rivals. They are bastards for whom he refuses all
responsibility.

Often he brings forward still other reproaches against
his wife. She is rude, extravagant, wants to get rid of him.

CLINICAL FORMS 231

to put him into jail or the madhouse, to kill him ; her lover
is helping her. A patient declared that his wife was " ment-
ally below par, depraved in morals, and of common, base,
bold, and stupid origin " ; she was good for nothing either
on land or water. Many patients give utterance to all kinds
of ideas of persecution. They are pursued b}^ the parish
authorities, watched by secret police agents ; everything
is found out by spies, letters are opened, details of their
life are told everywhere ; the doctor is in the conspiracy
with the wife. The patient mentioned above, described by
Jaspers, constantly asserted after a medical examination
that he had been officially declared insane, and in spite
of being told over and over again and in the kindliest way
that there was no foundation for his idea, he carried on for
many years an embittered struggle to obtain the annulment
of this supposed " declaration of insanity ".

At the same time a greatly exalted self-consciousness
frequently exists. The patient boasts of his " sense of duty
and unwearied diligence," he is a respectable citizen, he
only wants what is right, he helps everyone if he can, and
if it is right. " I always endeavoured to raise my stand-
point," declared a patient. The patient of Jaspers, who
was a very skilful watchmaker and had constructed a large
and very elaborate clock, spoke of the ingratitude with
which the Fatherland rewards its great sons. Others again
make the impression of good-natured, weak-willed personages.
Understanding for the morbidity of the ideas of jealousy
is entirely absent, though a patient did say to me that he
had always had a feeling of terror lest his delusion might
really be true. According to this it seemed that a period
of doubt had preceded in the patient who was wholly without
insight ; he even bored holes in the door in order to obtain
certainty by watching his wife.

Invariably great irritation at the husband or wife supposed
to be guilty develops in connection with the delusions. It
comes to violent reproaches and disputes. The patient
abuses his wife, tries to wring a confession from her,
threatens and ill-uses her. A patient carried about a
revolver with him and put it under his pillow at night,
because he had to shoot his wife or stab her. Another
spoke of ripping up his wife's belly. He did say afterwards
that that was " only a mouth expression." " That is a
thing that one does not do ; one says it only that the jaw
may have work." Nevertheless he became later very

232 PARANOIA

violent towards his wife. Even the cliildren are abused
and beaten. A female patient threatened girls in whose
compan}^ she had seen her husband. Another brought a
complaint against her husband of alleged incest. A male
patient brought an action against his supposed rival.
Another prosecuted three of his colleagues simultaneously
for adultery with his wife. Generally it comes to divorce
or at least to separation, and then the patients usually quiet
down by degrees without, however, the delusion being rectified.

Hypochondriacal Delusions. — A hypochondriacal form
is frequently described as another kind of paranoiac
delusion with depressive colouring. It is certain thai
hypochondriacal delusions are frequenth' expressed by
paranoiacs. Nevertheless I have not found it possible
in careful sifting of my experiences to find an indubitable
case of paranoia characterized only, or at least predominantly,
by this kind of delusion. I think, therefore, that I should
meantime abstain from the delimitation of a hypochondriacal
paranoia.

Delusions of Grandeur, Inventors. — In the various
clinical forms of paranoiac delusion of grandeur the principal
trends of human endeavour come to expression. The
delusional inventors form a first group. The patients do
not feel satisfied with their ordinary vocational activity,
and occupy themselves along with that with all kinds of
far-reaching, high-flying plans which gradually become the
real substance of their lives. The idea at one blow to
become world-famous and to acquire measureless riches
by inventions which cause sensations, hovers before them.
Without rudimentary knowledge, with wholly inadequate
resources, they set about realizing the ideas which occur
to them. They sketch out drawings, build models, search
for people who will give money, and they exert themselves
about patents. Sometimes it concerns plans for definite
practical machines or useful objects, for railway points, a
boot sole with a joint, an electrical regulator of beer-pressure,
a condenser for a refrigerator, a valve for hot air apparatus,
a motor plough, an aluminium coffin. In certain circum-
stances it may even happen that a usable idea is the
foundation of such inventions, but the patients wholly
lack the capacity to bring it into a useful form, as they
are not at all famihar either with the technical, or with the
business preliminary conditions. In their unprofessional
ignorance of the real circumstances they even frequently

CLINICAL FORMS 233

occupy themselves with problems, which long ago have been
satisfactorily solved by others.

It is just this naive ignorance which causes them very
commonly to turn straightway to the most difficult, indeed
to wholly insohible tasks. Specially liked are the following,
aeronautics, the utilization of the sun's heat and of natural
electricity, but especially perpetual motion, a " cheap
machine for the utilization of power without any supply
of power." With untiring ardour in spite of all dissuasions
and derision, drawings ever more extraordinary are made,
with which the patient expects to come nearer to his "goal.
For years he works at an impracticable model, fitting in
or replacing here a cog-wheel, there a weight or a stay, so
that the most remarkable monsters of wood, wire, lumps
of lead, gas-pipes, old bits of brass, arise, to the completion
of which the patient sacrifices every free hour and every
penny which he has saved.

The peculiarity common to all these inventors is the
unshakable faith in their star, in their great and unique
endowment, and their brilliant future. He arrived at his
inventions, of which he was still planning many, by his
innate talents, declared a patient. As one cannot sing
without a voice, neither can one invent anything, if one
has no organ for it. Another, a very poorly endowed patient,
compared himself with a well-known inventor, who had the
same name as his mother ; he visited in devout mood the
great man's grave, and developed the firm conviction that
he had left him an inheritance. The importance and
especially also the economical value of their own inventions
are immeasurably overestimated ; in the opinion of the
patients it invariably mounts up to at least millions. They,
therefore, are for the most part very secretive and fear
that their ideas, their intellectual treasure, may be stolen
from them. They consider that their task is completely
accomplished when they have brought forward some idea
or other and perhaps made a few clumsy drawings to
illustrate it ; there is no question of any real working-out
of their plans with accurate entering into detail. They
are always extremely satisfied with their models, innocently
overlook all difficulties and mistakes, and in spite of the
most obvious failures, ever again confidently declare that
only a quite unimportant improvement is still necessary in
order to reach the desired goal in a short time.

In other domains also this over-estimation of self is often

234 PARANOIA

seen. The patients make great plans for marriage, worry
with their proposals ladies who are unknown to them or
who absolutely refuse them, and are extremely astonished
that they are not accepted with open arms. A patient
said, " A Rockefeller would perhaps have said to me, ' Well,
my friend, all honour to you ! Here you have my daughter ;
I am your helper.' " They raise unfounded claims to
money, demand support from the state for their efforts,
expect confidently to be employed in prominent posts, as
they feel themselves equal to the higliest demands. Pseudo-
memories may also be coloured b}' their exalted ideas ; a
patient related that the minister had assured him that
money was lying ready for the working out of his inventions.
In their conduct the patients often display a certain dignified
reserve ; one patient let his hair grow long like an artist.

Naturally the actual results do not at all correspond to
the high-strung hopes. First of all the efforts to make a
practical use of the inventions supposed to be so brilliant,
to sell them, to obtain patents, fail. Perhaps the patient
has luck once and succeeds with some trifle, but the hoped-
for millions do not come in. The blame for this, in his
opinion, lies not only with his lack of means, which does
not allow him to take the realization of his plans into his
own hands, but also with the lack of sense of people who
do not know how to value his importance.

But often hostile machinations are what rob him of the
well-deserved fruits of his labour. He is hoaxed ; price-
lists of wine are sent to him in mockery of his poverty ;
people work against him everywhere, hinder him from
getting on, steal his inventions and make use of them. A
patient, to whom the idea, in his opinion quite new, had
suddenly come to construct a motor plough, and who shortly
afterwards found one advertised in the newspapers, at once
clearly saw that his childish drawings had been stolen from
him and with all haste made use of ; he always, therefore,
called himself the " plundered inventor." He said that by
his desperate poverty he was now a " laughing-stock,"
plundered, deceived, perhaps in the eyes of the whole world
ridiculous and despised as well. As aider and abettor in
the theft he suspected a young girl who had rejected his
proposals of marriage. Another patient wrote threatening
letters to a government official whom he considered
responsible for his not receiving a considerable sum of money
from public fimds which he had asked for.

CLINICAL FORMS 235

As a rule, the patients lead a quiet, depressed existence
but lighted up by the unconquerable hope of ultimate
success. They are not permanently discouraged by any
failure and they continue to work unswervingly at their
plans. Since for the most part they still earn their living
in some other way, they give no occasion for difficulties,
unless once in a while they are driven to unusual steps by
tlie struggle against their opponents or the attempt to procure
more means for themselves.

Delusions of Grandeur, High Descent. — A further
form of paranoia is dominated by the delusion of high
descent, which proceeds from the wish for power and riches.
The French speak of " genealogen," " interpretateurs
filiaux." ^ After perhaps long years of racking their brains
and dreaming, the certain conviction arises in the patient
that he is not the real child of his parents, but is of much
higher and more glorious descent. An affair of no importance
often provides the external occasion for the origin of this
delusional idea, which for him immediately attains to
indubitable certainty. In a dispute his father makes use
of a violent expression which he would never employ towards
his own child. The patient notices that his parents whisper
in the adjoining room, turn pale on his entrance, greet
him with peculiar seriousness ; in his presence the name
of a highly-placed personage is mentioned " significantly ".
On the street, in the theatre, some or other aristocratic
lady looks at him in an unusually friendly way. While
he is contemplating the picture of a count or a prince or
the bust of Napoleon, a surprising resemblance with himself
suddenly occurs to him, or finally a letter falls into his
hands, between the lines of which he easily reads the
significant information. A patient spoke of mysterious
revelations which he dared not communicate to anyone.

With pecuhar satisfaction the patient recognizes that
also by the people in his more immediate and more
distant surroundings the superiority of his person and of
his position is more or less openly acknowledged. Wherever
he goes, he is treated with unmistakable respect ; strangers
take off their hats to him with profound politeness ; the
royal family try to meet him as often as possible ; the
band on the parade or in the theatre begins to play as soon
as he appears. In the newspapers which are laid before
him by the waiter, in the books which the bookseller sends

^ Serieux et Capgras, L'encephale, i. 113, 1910.

236 PARANOIA

to him, he finds more or less figurative allusions to his
fortunes ; the passers-by on the street accompany him with
approving remarks full of meaning.

This delusion also is frequently accompanied by pseudo-
memories. In especial a number of alleged experiences of
childhood betray this origin. The patient remembers how
as a small child he was taken out of a beautiful castle from
his real parents, dragged about in the world, and finally
given a home with his alleged parents. He is still able
perhaps to describe the magnificent furniture and decoration
of the rooms, the beautiful park, in which he spent his
childhood. Many utterances and actions of his foster-
parents, the cut and colour of his clothes, the treatment
which he received at school, prophetic dreams, all events
great and small of his life have from his earliest youth up
pointed to his descent, to his future high calling. From
different sides straightforward communications were made
to him about his origin and his descent ; agents were
commissioned to offer him considerable sums of money to
come to terms, but he did not accept these.

In the further course the patient then gradually attempts
to make his supposed rights known. He confides in an
intimate friend, applies to the authorities, writes letters to
his highly-placed parents. For the most part he has the
feeling that he will scarcely find full recognition, and so he
endeavours to get at least the greatest possible sum that
can be agreed on. He considers himself justified in making
special claims for his position, sets a value on his appearance,
and at the same time has usually little inclination to lower
himself by regular work. Thus he finds himself obliged to
procure money on the strength of the recognition of his
important claims of which there is a certain prospect. As
he acts with great confidence, exerts himself to suit his
behaviour to his aristocratic descent and really takes, steps
to further the matter, he often succeeds in finding credulous
people who help him in expectation of great profit later.

He certainly meets with great opposition. Aristocratic
relatives try in their own interest to prevent the recognition
of his claims ; his life is attempted ; people try in every
way to render him harmless. Even the removal to a mental
hospital, which then follows when the patient has become
inconvenient by his always more urgent steps to make good
his claims or by the exploitation of his followers, is con-
sidered by him as a specially cunning trick of his opponents,

CLINICAL FORMS 237

who have already for long indicated to him that he must
end in insanity. At first he submits, as he is sure that
his mental soundness will soon be recognized. In all his
utterances he is very reserved, evades searching questions,
and conceals his delusional ideas under blameless behaviour,
till a special occasion, an emotional excitement, draws them
out.

Gradually it becomes clear to him that the physicians
are hired for the purpose of rendering him harmless and,
if possible, mentally ill, as he could not be got at in any
other way. Small unpleasantnesses and annoyances,
changes in arrangements, occasional remarks, show him
that the opposition and intimidation are set in motion by
the people in the new surroundings also. His fellow-patients
are not ill at all but bribed malingerers or pohce spies who
by their conduct and nonsensical ongoings are to " prove "
him.

Or the patient recognizes that the stay in the institution
only represents a necessary link in the chain of the tests
which he has to go through in order ultimately to reach
his high aim. Indeed, on more careful reflection it becomes
clear to him that already in his past life many indications
of this purgatory in the madhouse were present. Far
removed, therefore, from dejection and despair he draws
fresh hope of the attainment even of his last and highest
aims from the exact fulfilment of all that fate had previously
destined for him. This view of his not infrequently finds
special confirmation in the observation which he forthwith
makes that also in the institution the mysterious indications
of his brilliant future do not fail. He is treated with special
attention ; attar of roses is poured into his bathwater ;
he is flattered in figurative language ; newspapers and books
find their way into his hands, whose contents concern him.
It cannot, therefore, escape him that the physicians detain
him " on higher command," and do not at all think of
considering him really ill. Among his fellow-patients he
discovers very highly - placed personages who have been
placed in the institution under false names as companions
for him.

Sometimes the patients carry on prolonged and extra-
ordinary struggles for their liberation and recognition.
Others resign themselves to their fate with dignity in the
certain expectation that their time will come some day.
Serieux and Capgras have brought forward a whole series

238 PARANOIA

of historical claimants to thrones, of whom many have,
perhaps, been patients of the kind here described.

Delusions of Grandeur, Prophets and Saints. —
The delusion of anotlier group of paranoiacs, the prophets
and saints, of the " mystics," as they are, indeed, usually
called, goes out in the direction of the relations to the
transcendental world. A patient described the first
beginning of the malady as follows : —

" When I was abroad from 1866 to 1873, 1 gradually gave up all re-
ligious ideas. I was led to this by my travels in connection with my work
as carpenter or draughtsman in countries and among peoples of different
religions. So in this connection I thought at last that my conscience told
me what a man has to do and to leave undone, and if I act accordingly,
I do not need to be afraid even of death. But unfortunately in spite of that,
I felt an indescribable unrest in myself day and night which always got
worse. From this God by his grace at last set me free by means of a letter
from my mother to Vienna in the spring of '73, so that afterwards I had rest
and peace in myself, and on this account in gratitude for this I at the same
time also vowed to God the Lord to live and die for his holy word. For
this reason I returned to Saxony, and I caused a disturbance in Leipzig in
August '73 by some placards which I was going to post up during the night,
but I was hindered by the police, so that I was put in prison for some days . . .
On these placards I had given expression to my faith, that I believe that
God, who speaks to us in the Bible is our only Lord, which I am obliged to
believe unconditionally by reason of holy baptism and the triune God, and
at the same time I expressed myself in a contemptuous and in.sulting
manner about Kaiser Wilhelm . . . Till Whitsunday '75 I worked at my
calling again practically and theoretically. But my relations to my
parents became at last so strained that I completely disowned them on the
ground of my belief in God's word, and I even gave up the filial relation to
them and spoke to them as Mr and Mrs F. . . ."

The patients frequently occupy themselves with subtle
reUgious speculations of all kinds, theosophy, spiritism,
sectarianism. Visionary or ecstatic experiences then usually
acquire a decisive significance. The patient sees in the
night divine manifestations, and experiences at the same
time an indescribable blissfulness ; he hears the voice of
God, receives orders from him ; he sees the devil as well.
Christ appears ; at the same time a voice rings out, " Feed
my sheep ! " Gods calls out to him, " You are the only
one ! " A female patient perceived St Magdalene who
announced to her, " You were not born a beggar ; you
are chosen for something higher." " With this dream the
spiritual experiences began," she declared.

Now and then similar experiences take place during the
day. A patient beheld God at the moment when he
prayed, " Deliver us from evil " ; it went through and
through him hke a higher, invisible power, as if air were
breathed into him, as if fire passed through his fiesh and

CLINICAL FORMS 239

bones, as if the soul were leaving the body. Another
suddenly heard a voice from above, " You must go forth ! "
and after that he felt himself guided by a higher power ;
on another occasion when the clock struck three he felt
the Trinity in his breast which announced to him, " You
are the salt of the earth." He also once saw the sun rising
like an egg, and noticed that a gloriole surrounded him. A
female patient felt how she hovered above the ground in
church. It is certainly necessary in all stories of that kind
to reckon with the possibility of pseudo-memories. Invariably
such experiences, which are usually very exactly described
and referred to a definite day, remain isolated, although
now and then they are repeated in a similar manner.

Generally an extremely personal, self-confident working-up
of the experiences of life develops. The patient always
sees better into the truth, " sees all connections in his head,"
does not require to read any newspapers in order to know
what is going on in the world. When he has visitors he
feels immediately whether they have the right faith ; he
receives signs if people are pleased with him. He makes
" continuous observations," notices that his views are
carried further, his conversations are made use of. If he
has said anything beautiful, a beautiful man with a lilac-
coloured tie meets him, otherwise an ugly man with an
unpleasant colour. A patient attributed secret significance
to the appearance of the dogs which he met on the street,
" Black dog with a red ribbon round its neck — ^reactionary
who decorates himself with progressive feathers ; white
dog with blue bow — mawkish way of acting which points
to narrow-mindedness ; white dog with red ribbon — sickly
sweet behaviour with radical utterances."

The conviction apparently sometimes flashing out like
lightning, that he is a chosen one of God, becomes now
more and more fixed in the patient. He feels that he is
a prophet, " Elias redivivus," Redeemer, the Son of God,
the heavenly giver of the marriage feast who is to fulfil
the parable of the repeated invitation to the marriage feast,
to fight the great fight with Anti-Christ and to bring in
the millenium. He is the only one who has known God,
" knowing all, he alone only knowing," the highest judicial
authority in ecclesiastical and secular things, sent out from
the Father, called to redeem all mankind ; he must warn
the law-givers, he waits for what God purposes for him. A
patient declared that the heavenly Father sent a man every

240 PARANOIA

two hundred years who should make known to the Jewish
people (i) their fall, (2) the true faith. Another perceived
that his brothers had got up a comprehensive organisation
" with authoritative head, central personage, compensating
middle point," and he added, " I suffer from the megalo-
mania that I should be this centre ; that is my disease."
He described the origin of this delusion in the following
terms : —

" That my brothers got up the organisation, I can only with difficulty
decide, for I believe that is more a matter of feeling in me. But I will try
to explain how I arrive at this view. Although I cannot prove it I have in
myself the firm belief, that it is actually so. A very trifling incident was
the occasion. On the performance of some duty in the shop a workman
let fall the expression. That is one of the A. W.'s (initials of all the three
brothers). This saying of the workman confirmed in me what I had long
supposed."

It becomes clear to the patient that mankind is in terrible
confusion. Men do not look up to God ; what astronomers
and law-givers say, is untrue. The pope is antichrist ;
the resurrection of the dead and the last judgment are at
hand. Jesus was the serpent in the wilderness, a magician,
a lazy fellow, a thief, a murderer, a liar and deceiver ;
Paul, Peter, and James were false prophets. The Kaiser is
Saturn or Satan, whose son is the serpent that tempted Eve.
The reigning sovereign is well-disposed towards Satan.

Occasionally " genealogical delusions " also emerge. A
patient said that his true spiritual father was Kaiser Franz
Joseph ; his alleged father had appeared to him before in
a dream, and slid about before him on bloody knees, and
had asked him for pardon, because he had not known what
his son really was. Other patients have made important
inventions. Now and then ideas of persecution appear ;
the clergy wish to oppress the patient, the Kaiser causes
him the greatest torments ; in the bread there might be
something wrong.

Pseudo-memories frequently appear to acquire great
significance here again. The patient tells how everyone
was astonished at his beauty when he was born ; a neighbour
said, " That will yet be a Redeemer." Later some one
said, " A Messiah must come." A patient at the age of four
saw heaven opened. A female patient at the age of five
had a dream which was fulfilled, which then occurred to
her later. When her stepmother was going to punish her,
she dreamed it each time beforehand, and the same thing
happened when her sweetheart embezzled 15,000 marks.

Many patients ascribe to themselves the gift of prophecy.

CLINICAL FORMS 241

A patient asserted that he had foretold an earthquake ;
another prophesied, as it was said, conflagrations, the
recent wars, the cholera, the death of her sister, her removal
to the hospital. She saw a woman in Italy, who was
believed to be ill, standing before her house quite well and
combing her hair. In consequence of this she had a great
number of believers, and she asserted that there would be
a religious war, after which King Otto would become Head
of the Holy Roman Empire. Other confabulations are also
brought forward. A patient had met the apostle Paul in
the inn a.t his home, as an inward voice disclosed to him.
Another was cheated of threepence at a card game by Judas ;
a third stated that this was not the first time he had been in
the world.

A few patients apparently possess the power to put
themselves into ecstatic states. A patient said that the
theosophic discipline could develop in human beings organs
of sense and states of higher consciousness, of which the
ordinary average European knew nothing ; in this way he
perceived facts and phenomena in nature, which he had not
noticed before. A female patient made journeys at night
which she distinguished from her dreams. According to
her description she was then in ,her astral body ; she did
not need to drag her ordinary body with her ; she was
accompanied by an angel and a female saint. On her
return " her spirit oozed into her body hke oil in blotting-
paper " ; at the same time a hollow voice announced to
her the goal of her next journey (the underworld). As the
patient once slept for six months on end with short daily
intervals, it was probably a case of hysterical phenomena.

After a considerable period of preparation the patients
set about fulfilling their supposed mission. They try to
recruit followers by conferences, circular letters, sermons.
Generally they succeed in this. Their confident behaviour,
their firm convictions and knowledge of the Bible do not
usually fail of effect. Besides there is also the fact, as a
patient said, " In matters of faith no one can refute another " ;
" In matters of faith and conscience God himself can be the
only judge," declared another. The neighbours next
assemble out of curiosity in the patient's house, and are
astonished at his alleged power of prophesying, his addresses
richly garnished with verses from the Bible ; they give him
presents, hold prayer meetings with him and hope for special
grace from him.

242 PARANOIA

The " heavenly giver of the marriage feast," already
mentioned above, a master shoemaker, had a small congrega-
tion of seventeen people gathered round him, who for the
most part received his prophecies of the approach of the
millenium after the great and decisive battle with Anti-
christ very literally. Statutes of nobility were found in
his house and divisions into ranks and classes, as also
regulations for the most varied court servants (huntsman,
chamber-lackey, keeper of the wardrobe, master of ceremonies,
officer in immediate attendance for private affairs) " of his
Allholy Royal Majesty of the King of the eternal Jerusalem
of the kingdom of God on earth, of the King over all peoples
of the earth ruled by the sceptre of his Father the Creator
of the world, originated by the sign servant King David."
This was worked out with extreme neatness and in great
detail by one of his followers. The following short extracts
may give an idea of those remarkable documents : —

" The officials of the immediate surroundings of the King are : — i. the
General of the throne ; 2. the General Lord Chamberlain ; 3. the General
Comptroller of the Household ; 4. the Officers in immediate attendance
on the King; 5. the General Adjutant, Aide-dc-Camp, and the other
Adjutants ; 6. the General Master of Ceremonies with the other Masters
of Ceremonies ; 7. the Quartermaster-sergeant of the King ; 8. the Head
Body Servant of the King ; 9. the Huntsmen of the King, also the General
Officials of the Allholy Royal Lord Chancellor . . . That the Office of an
Allholy Royal Lackey ist Class be established according to the ordinance
of the King of the Allholy Royal 2nd Class of Court rank of the Officials of
Magnificence of the date of nth May 1898 at Wiirzburg for the official
with a definitely fixed yearly salary of 16,000 florins (ten and six thousand
Gulden), which is to be paid in monthly instalments of 1333 florins. Like-
wise an allowance for clothes of 960 florins will be allotted to the Chamber-
Lackey 1st Class, which also like the yearly income is to be paid in monthly
instalments at 80 florins per month . . . The change of dress of the King
takes place after each high service and that is in the morning at 4 o'clock,
and 6 o'clock and at midday at a quarter past i o'clock in the afternoon
till half past 3 o'clock, and if an excursion is fixed for the day in question
the change of dress takes place 20 minutes before the hour of departure . . .
The King's beer goes to the account of the restaurant of the officials of
magnificence, for which purpose the beer account book lies in the Chan-
cellor's Office of the Head Body Servant ... In all the apartments of the
Allholy Royalty wax lights will be maintained during the night to the end
of the world, which will be the wax lights of the large chandelier and the
wall brackets of the halls and rooms ... If a chamber-lackey has to
accompany the King during the promenade, he must walk on the left side
of the King, but the chamber-lackey must observe silence, unless the King
enters into conversation with him. For as always so also in such walks the
King must give the actual audience to his spirit, for which the King must
be undisturbed . . . The Huntsman must appear in strictly prescribed
service uniform which consists of coat, breeches, service shoes, huntsman's
hat, gloves, sword, spurs, and the usual service underwear. For service
the high official must have his hair dressed by his hairdresser and must also
be shaved every day, if there is a strong growth of hair. A beard may be
allowed . . . At 6 o'clock sharp in the morning the General Adjutant and

CLINICAL FORMS ' 243

the General Master of Ceremonies with two Masters of Ceremonies receive
the King in the cabinet, after which the remaining cortege in active service
then must take part. The remaining cortege joins the immediate cortege
from the hall of mirrors for attendance on, and further service of the King
at the table. Both the Huntsmen when they come to the table must place
the chair at the table for the King and place the menu card lying there in
front of him, after which then the girding of the King and the serviette
service must take place ; in the same way also the huntsmen must serve
the King with the newspapers lying on the table, that is the huntsman
must ask the King if he wishes a newspaper and which newspaper . . .
During the time of service in the table-hall all unsuitable approaches to
ladies, which might reveal a kind of love-affair or paving the way to it,
are most strictly prohibited, as it would be a gross breach of the etiquette
of the Court."

Further on the subject is the " Order of the two heavenly
brides," by which a knight of the realm is raised to the
highest rank of the nobility with elaborate ceremonial, the
four-in-hand with silver trappings which the knight must
keep, the ancestral hall, which he must furnish for himself,
the service dress which may not be spoiled by rough wear
or perspiration, the necessity for the court officials " to take
a bath often," and by means of beard-brushes to clean
the moustache from soiling by tobacco. The investiture
of all the officials of magnificence takes place " on the day
of the elevation of the king over all the peoples of the earth " ;
the kingdoms of Judea, Samaria, Galilee, Idumea, and Perea
will be incorporated in his seat of government. As garments
of the King there are mentioned, " vestments of the service
of the absolving power," highpriestly service vestments,
official teachers' garments, ornaments of the government,
ornaments of church festivals, ornaments of secular festivals,
house-garments, which are all accurately described. The
number of the court officials runs up to 157, from the first
throne-bishop primate, general throne master, throne general,
general treasurer, general keeper of the archives, a crowd of
directors general (and others of the cabinet upholstery
school, hat-making school, cuirass-tailoring school, of the
private journals) to the general court marshal, general
equerry, general master of ceremonies, physician to the
King, barber, hairdresser, chef, general master of fisheries,
throne notary, stamp officials, and so on. The naive view
of future magnificence which appears in those documents,
returns frequently in the formation of sects and in religious
foundations. It can easily be understood that paranoiac
patients of the kind here described have not infrequently
become the founders of large communities.

Further steps which the patient may take, consist in

244 PARANOIA

directing letters to the spiritual and secular authorities and
explaining his mission to them or declaring feud. An
example of this is given in the following extract : —

" The hour namely has now come when you cathoHc clerical brood have
played out the game with your mockery of Me and My sacred writings !
Now follows namely the reckoning for your misdeeds ! i.e. I now challenge
you yourselves along with your antichristian scoundrels on the sacred chair
in Rome to come, and meet me again and my scriptures with your well-
known mockery and your other base calumnies and therefore this, that
according to the Revelation of St John the preparation for the settling of
accounts for your misdeeds against me may be made. The preparation
for this will namely be made not only by that kind of earthquake and
volcanic eruptions, that there will be a general lamentation ! There
would also be made the further preparation for this by that kind of dis-
ease, famine and misery that catholic Christendom would already be wholly
extirpated from the earth, as soon as it would even not yet be separated
by the earthquakes and volcanic eruptions from you paltry < iiii,,)ir
parsons."

Others set about writing a book discussing the most
important truths ; perhaps the third Testament, said a
patient. The " heavenly giver of the marriage feast "
fulfilled the parable by twice sending out the invitation
in the form of comprehensive missives about the approaching
millenium. The archbishop received a book weighing two
and a half hundredweight. As, thereupon, nothing resulted
except a complaint of disturbance of religion, the patient
declared that he had now fulfilled his task, that he would
acquiesce and would let perdition take its course. Another
patient appeared on the streets of Munich decorated with
silver gauze and with a board hanging from his neck on
which was the following announcement : —

" Hither and no further goes the Word of God. Do penance, for the
end of Europe is near. For ten years you have still time to do penance
and then in the whole of Europe there will not be a single human being
left."

He also was arrested and returned quietly to his own
home, as he had now done his duty. Another patient
travelled over the world, crossed the ocean twelve times,
felt himself impelled to go to the Jews, who keep the law.
A female patient travelled with the assistance of her followers
to Vienna, in order to exorcise the plague by her penance
which she carried out in numerous churches. Many patients
feel that they are called to reform the world, to make people
happy. A Hebrew patient urged with the greatest obduracy
and in ever repeated petitions to representative bodies
the keeping holy of the Sabbath day, and the payment
of tithes by the^Jews, as also the free distribution of bread

CLINICAL FORMS 245

twice daily. He also desired that the fish in the sea should
be fed and ascribed accidents at sea to this sin of omission.
In a petition to the association of landlords he urged the
hanging up everywhere of boards with rules for health
printed on them : " One must never breathe through the
mouth — One must never spit on the floor, and not on the
street, only into a handerchief." On the road he reminded
people that they should not sit down on stones, lest they
should catch cold, advised policemen not to expose them-
selves with their helmets too much to the hot sun, but
rather to walk in the shade.

The outward behaviour of the patients is usually in
general quite orderly. For the most part they follow a
calling, and frequently they appear to the people in their
.surroundings as specially gifted intellectually. They have
usually great facility in speaking, can deliver long, flowery
discourses of apparent profundity although very confused,
in unctuous pulpit tone. A p9,tient, already mentioned
several times, regularly published for his followers a hecto-
graphed magazine, " From the School of Light," in which
he spread himself at large over the most varied religious
questions, but especially over the events at the creation;
the discovery of fire, the life of antediluvian people. For
his birthday a special number always appeared ; I reproduce
the title-page of one of them (Fig. 49). In cases of death
in the " congregation " announcements of the death w^ere
published, in which the pleasures of eternal life I were
promised to the departed who had taken an intimate part
in all that happened in the sacred cause and had made
great sacrifices to God of earthly possessions. His
" spiritual God-man-nature " would enjoy these pleasures
till the last day and then as a noble servant of God, risen
anew in the body, would be sure of the greeting " My
Allhighest Royal Majesty, the King's Son." The patients
always exhibit great self-consciousness, sometimes concealed
only by affected modesty. Many even try to express their
sacred mission in their external appearance ; they let their
hair and beard grow long and they put on a kind of garment
such as Christ is represented as wearing.

Delusions of Grandeur, Eroticism.— This has still
to be mentioned as a last form of paranoiac megalomania.
The patient perceives that a person of the other sex,
distinguished really or presumedly by high position, is
kindly disposed to him and shows him attention which

246

PARANOIA

Zu filler oles tiuebursla^s unseres
Herrn u.Meislerssorpiezuneier
des25.3"ul)i[auTns^emernonen
Miss\onstriai\^ke\tals eruig ICgt
Woch2eitmah(gGber.

\ 19.41 05".

Fig. 49. — Paranoiac Title-page.

CLINICAL FORMS 247

cannot be misunderstood. Sometimes it is an intercepted
glance, a supposed promenade before the window, a chance
meeting, which lets this hidden love become certainty to
the patient. A female patient noticed that the reigning
sovereign bowed with special respect to her in the theatre,
and made his children greet her. Kisses, were blown to a
patient. Others receive information about the affair only
in circuitous ways by figurative allusions in their surround-
ings, advertisements in the newspapers, without perhaps
their ever having seen the object of their interest.

Very soon the signs of the secret understanding increase
in number. Every chance occurence, clothing, meetings,
reading, conversations, acquire for the patient a relation
to his imagined adventure. His love is an open secret and
an object of universal interest ; it is talked about every-
where, certainly never outspokenly but always only in
slight indications, the profound meaning of which he
understands very well. Pseudo-memories are frequently
mixed with these. Of course, this extraordinary love must
meantime be kept secret ; therefore, the patient receives
all messages in indirect ways, always through the mediation
of others, by the newspapers, and in the form of concealed
remarks. In the same way he can put himself into
communication with the object of his love by the occasional
dropping of hints. The flight of pigeons, which represent
symbolically himself and his beloved, shows him that he
has been understood, that after long struggles he will at
last reach his goal. Anyone with whom he comes in contact,
appears to him to be the chosen one, who has disguised
herself in order to conceal her affection from the world,
indeed, a secret prescience enables him at such a moment
of recognition to ignore the most palpable dissimilarities,
even the difference of sex.

A patient who importuned a rich lady with offers of
marriage after having met her twice in a casual way, saw
her again later under another name ; she cast glances at
him. Then he met her quite changed under still another
name as patient in one mental hospital, as nurse in another ;
fellow-patients and the clergyman spoke about his affair
in hidden words. After he had received a letter to her
returned with the notice of her death — written by herself,
as he perceived — he enquired after her and found her now
married.

This peculiar delusion may for a long time be further

248 PARANOIA

elaborated in the manner described, nourished especially by
means of figurative advertisements in the newspapers,
without anything wrong apj^earing in the remaining
activities of the patient, who, indeed, tries to keep his affair
secret. In the further course dreamy hallucinations not
infrequently are associated with the delusion, the feeUng
of a kiss in sleep and similar things. The whole colouring
of the love is at the same time visionary and romantic ;
the real sexual instinct in the patient is often slightly
developed or developed in an unwholesome way (onanism).

Finally, the patient resolves on further steps. He
promenades before the window of his adored one, sends a
letter to her or manages to have conveyed to her a proposal
of marriage in due form. The refusals, which now follow,
perhaps offend him profoundly at first, but then appear
to him only as a means to put him on trial. In this view
he is strengthened by the experience that the former
mysterious relations continue. By means of advertise-
ments in newspapers he is invited to a rendezvous ; remarks
of passers-by indicate that he should go to his loved one ;
he has a feeling as if he had neglected something if he does
not do it. A female patient for several decades received
news in the feuilleton of the newspapers from her highly-
placed beloved, whom she then used to answer by letter.
In this way she learned that he had dispatched a marriage
contract to her, bought a house for her, and had set aside a
yparly income of 30,000 francs for her.

Meantime, things take an unfavourable turn. In the
case mentioned the loved one became unfaithful, as a
captain's widow had bound him in the fetters of love for
fifteen years. The marriage contract was suppressed ;
people wished to prevent the marriage. Evil reports were
spread abroad. A court lady set about boxing the ears
of the patient publicly and so making her impossible ; the
cook was incited by a jealous princess to poison her.
Morphia was scattered in the beds ; there was poison in
the night-light ; gas came up from below. Thus the loved
one can become the enemy and the persecutor of the patient,
or she will at least break his pride and then marry him.
She sends spies everywhere after him, has his affairs secretly
examined, prevents him from getting a good post. His
name is wrongly written on letters, at the end the " yours
most respectfully " is left out ; people jostle him on the
street, put out their tongue at him, spit in front of him.

CLINICAL FORMS 249

The food causes him stomach trouble and indigestion,
evidently in consequence of admixtures injurious to health,
so that he must do hi? own cooking ; on this account he
writes threatening letters, and appeals for protection to the
police.

As can already be seen from the descriptions given, the
varieties of paranoia here kept apart from each other are
by no means sharply delimited forms of disease. Rather
do the individual forms of the delusion quite commonly
combine with each other, but in an irregular way. As a
rule, however, no great difficulty will be found in placing
individual cases in the various groups, if the main direction
of the development of the disease is taken into account.
Now and then there are certainly cases whose assignment
to one or other form is in some degree arbitrary. Of the
individual forms of the delusion those of persecution,
jealousy, and religion appear to me to be the most frequent ;
but it may be that these morbid states have only more
especial need of psychiatric care.

CHAPTER IV.

COURSE AND ISSUE.

The general course of the malady has been repeatedly
indicated in our description. The development always
takes place very gradually, so that, as a rule, the beginning
of the morbid manifestations can scarcely approximately
be fixed. One speaks therefore of a period of preparation,
in which, as precursors of the actual delusion, premonitions
and conjectures emerge which again disappear, are forgotten,
or perhaps rectified. Many patients express themselves
with great reserve about their ideas even when from
their whole conduct one is forced to the conviction that
their system is firmly rooted. Such a patient came to ask
if his ideas were insanity or reality.

The two opposed directions of the delusional formation
may be from the beginning recognizable side by side. The
patient perhaps already believes that he is not treated with
due affection by his parents and brothers and sisters, but
he is often misunderstood ; for his peculiarity there is no
comprehension. Thus a quiet opposition, gradually in-
creasing, is developed between him and his surroundings.
To his family he is as a stranger, as a being from another
world ; his relation to them is cold, external, unnatural,
even hostile. " God is my father and the Church my
mother," said a patient, who through frequent fasting
wished to mortify his earthly self and so come into an
intimate relation with God. The patient therefore with-
draws himself from his family, behaves in a brusque,
repellent way towards them, seeks solitude in order to be
able to commune undisturbed with his thoughts, occupies
himself with unsuitable reading which he does not under-
stand. But at the same time a profound longing stirs in
him after something great and high, a secret impulse to
enterprise, the silent hope for an inconceivable happiness.
More and more the conviction is strengthened in him that
he was born for something " special." He believes in his
" destiny," in his mission which he has to fulfil.

What in the end brings the delusion to definite recognition

COURSE AND ISSUE 251

appears not infrequently to be something in itself quite
insignificant, as in the case described above of the patient
who doubted as to the reality of his delusion. There also
where the delusional formation is connected with visions or
ecstatic states, one may assume a sudden emergence of the
delusion. In other cases the delusional enlightenment begins
in the patient, as is alleged, with experiences which are
without doubt characteristic pseudo-memories.

The further development of the delusion takes place as
a rule extremely slowly. In isolated cases, as Jaspers has
shown, the delusional experiences may be crowded together
in a very short period of time, so that afterwards there
essentially follows only the working-up of them by logical
conclusions and confabulating decoration. It has been
already mentioned that occasionally also hysterical, or at
least psychogenic, changes of consciousness may be inter-
polated ; they have apparently a certain relationship with
cases which we find in the delusion of persecution in
prisoners and in induced insanity. Mostly, however, the
formation of delusions proceeds only very gradually, perhaps
indeed with greater or smaller exacerbations ; the old
circles of thought become wider and richer ; new ones
are added and they influence perception, interpretation,
memory, and power of imagination in their own way.

Issue. — But generally a period of the disease can be
distinguished, after which the delusion is in the main closed,
and is no longer extended in its fundamental features,
although it may be in details. The natural issue of paranoia
accordingly is probably, as a rule, a residual delusion. The
production of fresh delusions gradually abates, sometimes
sooner, sometimes later, but the delusional system once
built up generally continues unchanged in the main. Small
extensions are perhaps still possible, and secondary features
may fall into oblivion or even experience certain trans-
formations, especially by pseudo-memories, but the essential
delusional content remains the same. In the course of
time, however, the strength of the emotional emphasis of the
delusion and with that the driving-power for its development
usually diminishes slowly. The patient brings, it is true,
his delusional ideas to the front in the old way and at the
same time • also perhaps shows still a certain ardour, but
they do not occupy him any longer continuously to the
former extent. With that they also lose more and more
their influence on his actions. The patient no longer resists

252 PARANOIA

the persecutions with the old energy, strives no longer
passionately towards his high goal, but he yields to his fate,
and tries, as well as he can, to come to terms with circum-
stances.

A patient sent the following document to me : —

" If I now am silent to all insults, the day will still come, when all that
will come to the light of day, what a base game has been played with me.
In Munich alone there are thousands who know that I am not insane, that
I only must be insane in order to be deprived of my inheritance. But
these stubborn gentlemen may wait for long till I take measures against
my oppressors. Oh, no, I am not going to do such a thing in my old age and
I am quietly waiting for the issue, whatever may come."

A patient, already mentioned above, who considered
fasting, prayer, and silence necessary on religious grounds,
wrote as follows : —

" As I have been deprived of my legal rights by the authorities and have
been declared of unsound mind, it is absolutely justified that I should ex-
press myself in writing ; right is on this account absolutely on my side.
But as this cannot be well carried out in practical life, I only make use of
it in the case when conscientiousness compels me to do it, which namely is
justified towards those who know my .sad circumstances."

Genuine weakmindedness does not seem to be developed
even after very long duration of the disease, although often
the delusional ideas and what they are founded on, are
fairly indistinct and senseless. I had the opportunity of
observing a female patient till beyond her ninetieth year,
who had fallen ill at the age of forty-three. Except a
certain senile forgetfulness no sign of psychic weakness had
appeared ; in carriage and behaviour also the patient
displayed no disorder of any kind, while she firmly adhered
to her old delusions throughout.

Only a cursory reference is required to the fact that the
development described here of the paranoiac personality
merely represents a morbidly distorted picture of the changes
in general which human thought and endeavour undergo
in the course of a lifetime. The exuberance of youth urging
to great deeds and experiences ebbs gradually against the
resistance of life, or it is guided into regulated paths by
the ripening of volition which is conscious of a definite aim.
Disappointments and hindrances lead to embitterment, to
passionate struggles, or to resignation which takes refuge in
trifling pursuits and consoling plans for the future. But
gradually the elasticity disappears ; thought and volition
are benumbed in the narrow circle of everyday life, only
now and then are they revived by the remembrance of
former hopes and defeats.

CHAPTER V.

FREQUENCY AND CAUSES.

The frequency of paranoia in my experience does not nearly
amount to one per cent, of the admissions, the reason of
this probably being that the majority of the patients do
not require institutional treatment or only require it
temporarily. In Treptow Mercklin saw one paranoiac in
about two hundred admissions. In order to throw light
on these facts I give a survey of the duration of the disease
up to the entrance into the institution for the small number
of cases in which a fairly certain judgment could be made :—

Duration in Years 3 4 5 6 7 9 lo 12 14 17 21 26 41 44
Cases . .61111231111111

It is seen from this that the half of the patients lived
undisturbed for more than nine years in freedom, before
they came into the hands of the aHenist ; not altogether
infrequentl}^ over twenty years elapse up to that point, now
and then over forty years. Even then the residence in the
institution, as a rule, only lasted a comparatively short
time, as the patients were ready and able to comply with
the demands of the life of a community. Only the claimants
to thrones and similar patients, who habitually trouble
highly-placed individuals and the authorities in a querulant
way or exploit other people, suffer a fairly long deprivation
of freedom. For these reasons it is very difficult for the
individual alienist to collect facts about paranoiac patients
to any great extent himself, a circumstance which certainly
must be made partially responsible for our defective know-
ledge of this domain and for the great differences of opinion.

As far as the small series of observations, which are at
my disposal allows of a judgment, the male sex appears to
have a considerably larger share in paranoia than the
female ; almost 70 per cent, of my patients were men.
They are specially in the majority, as can easily be under-
stood, among inventors and founders of religions, while in

254 PARANOIA

erotic delusions and delusions of persecution women are
fairly well represented. The age at the beginning of the
disease was in two-thirds of the cases above thirty, relatively
most frequent between the thirtieth and fortieth year. In
isolated cases the traces of the disease could be followed
back to the sixteenth or eighteenth year. On the other
hand I have never been able to convince myself of a really
" idiopathic " origin of the delusional ideas reaching back
into early childhood, as Sander had in view in classifying
as a separate form his " idiopathic paranoia." Much rather
in such narratives of patients it invariably concerns pseudo-
memories. The remarkable utterances and experiences
narrated with extraordinarily exact detail occur to the
patient subsequently, when he examines his whole life
minutely like an open book ; before that they had made
no impression at all upon him and were quite forgotten.
Not infrequently, moreover, the cases idiopathic in this
sense, belong to dementia praecox and quickly become
demented ; others exhibit the picture of confabulating
paraphrenia.

Hereditary Relations and Psychopathic Predis-
position.-— I scarcely venture to say anytliing about tlie
hereditary relations of the patients, not only on account
of the small number of observed cases, but especially also
because the information about the family history in these
patients, of whom two-thirds entered the hospital first
after the fortieth year, is much too uncertain. A whole
series of them had led such a wandering Ufe that one was
thrown solely on their own statements, naturally very
unreliable. In such circumstances I place no value at all
on the fact that in rather more than one quarter of the
cases psychic disease was stated to be present in one of
the parents. It is perhaps more important that in more
than half of the cases personal peculiarities were reported
to us, which allowed us to conclude that a psychopathic
predisposition was present. An irritable, excited, occasion-
ally rough and violent behaviour appeared to be the most
frequent. Other patients were distrustful, self-willed,
superstitious, or ambitious, aspiring, unsteady, untruthful ;
still others were weak of will and poorh^ endowed. Several
patients showed homosexual tendencies ; some had for long
suffered from nocturnal enuresis. If accordingly in the
meantime there can be no talk of a uniform paranoiac
predisposition, so much may yet be said that the^patients

FREQUENCY AND CAUSES 255

frequently exhibited from the beginning distinct personal
peculiarities, which must have made the fitting into the life
of a community essentially more difficult.

External occasions do not play any part at all in the
history of origin, or at least only a very subordinate part.
Even the unpleasant experiences now and then reported
appear to me to be of significance at most for the content,
but not for the origin of the delusion ; often they were
obviously only the consequence of morbid behaviour. The
insidious development of the malady might itself give
evidence for the fact that the morbid process is engendered
by internal causes, and general opinion tends to the
assumption that we have before us in paranoia an expression
of degeneration. If we agree to this view with regard to
the peculiarity of the malady and to the frequency of
preparatory psychopathic features, then we find the further
question in front of us, which was sharply circumscribed
especially by Jaspers, whether paranoia is to be conceived
as the logical development of an abnormally predisposed
personality, or as a process which from a given point of time
onwards brings about a morbid transformation in a hitherto
healthy individual.

The former view corresponding, perhaps, more to the
opinions of the French investigators, has recently been
represented among ourselves especially by Mercklin and
Gaupp. Merckhn speaks directly of " paranoiac germs,"
which are said to come later to development in the disease.
In support of this opinion the multiplicity of the delusional
systems could in the first place be advanced, which in spite
of the return of certain fundamental features, yet lends to
each individual case its wholly personal stamp. Against
it may be objected that even a morbid process, which perhaps
only involves certain of the highest psychic capacities,
would leave wide room for the play of the influence on the
clinical state of the personal peculiarities of the patient.
3ut, further, it is perhaps worthy of notice that the various
directions, which the delusions take in paranoia, correspond
in general to the common fears and hopes of the normal
human being. They, therefore, appear in a certain manner
as the morbidly transformed expression of the natural
emotions of the human heart. Meanwhile we find similar
relations also in severe, destructive diseases of the brain,
as in paralysis and dementia praecox, a sign that just the
content of the delusional ideas is everywhere determined

256 PARANOIA

partly by the common requirements of the emotions. It
would, indeed, be difficult to understand whence otherwise
the delusion should take its form.

But one may yet, perhaps, take up the standpoint that
the connection of the delusion with personal peculiarity
in paranoia is essentially more intimate than in the
diseases mentioned. Without at all taking into account
the fact that the million-blissfulness of the paralytic, the
delusion of telepathic influence of the early dement is
repeated much more uniformly, the roots of the delusion
in paranoia, which appears later, can not at all infrequently
be discovered in definite, preparatory features of character.
The strong emotional emphasis of the experiences of life,
and what is connected with that, the personal colouring
of the relations to the external world in both hostile and
friendly sense, appear to me very commonly to come into
consideration here. Then also the feeling of personal
uncertainty along with distrust plays a part and also the
ambitious, passionate striving for recognition, riches, power,
with measureless overrating of self. Here we have before
us in a certain degree the component parts from which the
development of a paranoiac view of Ufe and the world could
to some extent be explained. They carry in themselves the
preliminary conditions not only for a lasting disproportion
between wish and reality, but also for the influence on the
whole view of life by this inward dissension. Specht has
expressed the opinion that circumstances in life which bring
about a conjunction of high tension of self-consciousness
with insufficient outward recognition favour the development
of paranoia ; as example he mentions elementary school
teachers.

If we now try to approach the question, under what
premises in the one case the delusion of persecution, in the
other the delusion of grandeur develops from the paranoid
disposition, this might perhaps be thought of, that the
original temperament, the tendency to a rosier or gloomier
colouring of the experiences of life, guides the delusion
formation sometimes in the one, sometimes in the other
direction. If the previous history of our patients is
examined minutely, a certain justification for this assumption
cannot be withheld ; an embittered, rancorous view of life
appears indeed often to prepare for the development of
the delusion of persecution, assured self-confidence for that
of the delusion of grandeur.

FREQUENCY AND CAUSES 257

Against such a simple assumption meanwhile the
experience to some extent tells, that we find with extreme
frequency both trends of delusion present at the same time.
The attempt has usually been made to explain this con-
junction by a kind of more or less clearly conscious
deliberation. The patient fulfilled with ideas of grandeur
is said to be forced to the assumption of hostile machinations
by the resistance which he comes up against in the
realization of his plans. On the other hand it may be
objected that from those points of view a development of
that kind might be expected invariably also in other
diseases with delusions, which only happens to a rather
limited extent. In any case the assumption may be
defended that the struggles and difficulties in which the
patient becomes involved partly by his delusions, partly
on other grounds, are of considerable significance for the
development of the delusion of persecution. Without
taking the fact into account that in the prison psychoses
we can follow with e^cperimental directness the development
of the ideas of persecution under the pressure of adverse
fortune, we can also observe not infrequently that ideas
of injury are added to the delusion of grandeur when the
patients fall into difficult positions in life and come into
collision with serious resistance.

But one may perhaps go still further and assume that
in certain circumstances their insufficiency for the struggle
with life arising from defective predisposition must be
regarded as the root of their ideas of persecution. A man
who is dominated by a secret feeling of uncertainty and
sees himself hindered by his weakness in the fulfilment of
his life wishes, is only too much inclined to suspect dangers
and to lay the blame of his failures on external influences.
Not infrequently we find that, when they have the
opportunity, paranoiacs try from the outset to withdraw
themselves from the serious struggles of life in the conscious-
ness of their vulnerability ; they do not take a fixed
situation, but wander restlessly about, occupy themselves
only with amateur occupations, and avoid contact with life.

If the incomplete equipment for the surmounting of
life's difficulties and the opposition to the surroundings
which results, were an essential foundation for the delusion
of persecution, its incurableness could also be understood.
For this disproportion continues to exist and is permanent.
While in the prison psychoses the mainsprings of the

258 PARANOIA

delusional formation are relaxed by the discharge of the
patient to freedom, the feeling of defencelessness towards
the hostile forces of life is renewed here every day. That
in spite of this the delusion generally begins only in the
third or fourth decade, could be explained bj^ the gradual
loss of youthful elasticity which at first compensates for
every failure by the awakening of fresh hopes for the future.

It must, however, be understood that in the paranoiac
formation of the delusion still a further circumstance must
play a part. We come across numerous psychopaths who
are not equal to the battle of life and avoid it without
developing ideas of persecution. What characterizes the
paranoiac is his resistance, his passionate struggle against
the injuries of life, in which he recognizes hostile influences.
Just here it is seen that the delusion forms a component
part of the personality. Failures are to the patient not
chance events nor are they due to his own fault, but a
wrong inflicted on him, against which he opposes himself.
This manner of reaction appears to me_to point to the fact,
that in him even when he is permanently conscious of his
inward uncertainty, an increased self-consciousness is present
at the same time ; it is this which causes his special
sensitiveness. If we might assume that, the frequency
of exalted ideas along with the delusion of persecution could
be in some measure understood.

The paranoiac delusion of grandeur has often been
derived from the comprehensible estimation of the enormous
sources of power which are at the command of the
persecutors ; in this way, it is said, the patient acquires
the idea of the very special significance of his own person.
That appears to me to be an artificial assumption. We
should then observe similar ideas in melancholic patients,
but that does not occur unless manic admixtures are present.
An egocentric direction of thought cannot be straightway
connected with the delusion of grandeur in any case.
Against that, besides the spinning of high-flying plans of
youth across into riper years, still another source of
paranoiac ideas of grandeur can be imagined, which possibly
arises not far from the first one.

The struggle with hfe may favour this direction of
thought in two ways. HumiUations may rouse to defiant
and exaggerated self-appreciation, which in the strongly
emphasized sense of personal value creates a counter-
balance to the neglect shown him by the outer world, or

FREQUENCY AND CAUSES 259

else defeats and disappointments lead to submersion in
a kindlier world of visions, as we have seen them do in the
presenile delusion of pardon. If the delusion of grandeur
in youth, full of the joy of hope, is intoxicated by its feeling
of power because it does not know the seriousness of life
and its resistances, the depressing experiences of life's
struggle are here pushed aside because they cannot be
conquered. Especially when the weapons fail, which are
necessary for the conquest and subjection of the opposing
hindrances, tenacity and endurance of volition, self-
assertion is forced into one of these paths both of which
lead to the delusion of- grandeur, it may be by arrogant
opposition towards the judgment of others, it may be by
escape into hopes for the future which no misfortune is able
to destroy.

Perhaps it will be possible some day to follow clinically
the various developmental possibilities of the paranoiac
delusion of grandeur. When it dominates the morbid
state from youth up, we shall be able to think of its origin
more from self-complacent dreaming. But when it develops
in connection with ideas of persecution and first in riper
years, it is probably more a defensive measure against the
depressing influences of life. While the delusion in the
former case betrays its history of origin in its romantic
colouring, in its fund of pseudo-memories and delusional
inventions, it is limited in the latter substantially to a
measureless over-estimation of personal capacity. Lastly,
likewise in later life, with or without connection with ideas
of persecution, especially in weak-willed or otherwise in-
sufficiently equipped natures, a delusion of grandeur may
attain to development, which bears features similar to
those in the first case, and which is a kind of psychological
compensation for the disappointments of life. It must be
left to the future to investigate whether these forms, in
the first place derived from certain premises, can actually
be found in experience ; probably they will often blend
with one another.

The emotional premises described above may well
explain the development of delusional ideas, but not their
peculiar paranoiac form. In any case by no means everyone
who exhibits the peculiarities mentioned becomes paranoiac.
There must be other circumstances which make the estabUsh-
ment and the psychic working up of the delusion possible.
The surprising failure of criticism towards the emerging

26o PARANOIA

delusional ideas has often been pointed out here ; it lets the
patient fall a victim to their influence without making any
resistance. This lack of judgment has mostly been regarded
as an indication of a certain psychic weakness. In reply it
must first be remarked that the delusions of the paranoiac
according to the explanations just given probably have their
root in emotional tensions, such as in normal people also
usually encroach to a great extent on the capacity of forming
objective judgments. As is well known, the firm persistence
of political and religious convictions illustrates this ; they
are not acquired, as a rule, by personal psychic work, but
are inoculated by the emotional influences of education
and of example, and in this way " grow round the heart " ;
even in regard to such convictions purely intellectual
considerations often fail in an otherwise incomprehensible
way.

Meanwhile without taking into account the emotional
mooring of the paranoiac delusion, certain imperfections
in the intellectual functioning in our patients might also
essentially contribute to lessen their capacity for resist-
ance to the emergence and interference of delusional ideas.
As it appears to me, the delusional formation of the
paranoiac exhibits many noteworthy points of agreement with
undeveloped thinking. In the first place visionary longing
for impossible goals not subdued by sober deliberation,
ideals as they are apparently often formed by the foundation
of the paranoiac delusion of grandeur, are found in similar
manner in youth. Later, with the maturing of judgment
the experiences of life surely and irresistibly lead to a
restriction of hope to the attainable, while in the paranoiac
the conviction becomes just then firmly rooted that he
is near the fulfilment of his dreams. Even the peculiarly
romantic colouring of the paranoiac delusional structure,
the picturing of princely and kingly magnificence, the
quietly blissful, sweet secret of the erotic delusion, the
tendency to day-dreaming and to the transformation of
the world according to immature personal wishes remind us
strongly of similar creations of the power of imagination
in youth. The same holds good for the bungling of the
inventors, which we find again in the clumsy but laboured
attempts of our children enthusiastic for the wonders of
technique.

Further, it must be pointed out that the egocentric
trend of thought, the peopling of the external world with

FREQUENCY AND CAUSES 261

friendly and with hostile powers, the superstitious inter-
pretation of events, in short the whole foundation of the
delusion of reference represents a common peculiarity of
psychically undeveloped peoples and human beings.
Dromard ^ speaks in this sense of infantile features in the
thinking of the paranoiac. The more remote that thinking
is from the stage of purely sensuous experience, the more
conceptual general ideas are developed, all the more does
the personal colouring of intellectual functioning grow
pale, and all the more does judgment become objective.
But, lastly, it would still need to be emphasized that also
the sprouting up of fully formed convictions inaccessible to
doubt is a process which we find again in the same way at
the lower stages of the development of thinking. Certainty
is the natural, the self-evident thing ; doubt is the bitter
fruit of ripe experience.

We come, therefore, to the conclusion that a number
of peculiarities adhere to paranoiac thinking which we are
justified in regarding as an indication of developmental
inhibitions. They may lead to this, that habits of thought,
which otherwise are more and more overcome with the
ripening of the psychic personality, here continue per-
manently, and with corresponding emotional predisposition
gradually cause that falsification of the views of life which
characterizes our disease. If one will, one might say that
the world of ideas of a savage, who sees himself surrounded
by demons who lie in wait for him everywhere, and perceives
innumerable signs portending disaster or good fortune,
or of a medicine man, who has at his command the magic
powers of the fetish and produces supernatural effects by
his incantations, does not fundamentally differ very much
from paranoiac delusional systems. Only in the former case
it concerns stages of general culture, in the latter purely
personal morbid development.

It has further to be remarked that we must, of course,
not regard the paranoiac simply as a grown-up child. Rather
it might be assumed that in him an unsymmetrical develop-
ment of the psychic personality had taken place, and so
only certain domains of the psychic life had remained
immature. It would accordingly concern a kind of
distortion of the psychic picture, in which the individual
features developed in various ways mutually influence and
disturb each other. Thus the firm tenacity also of the

^ Promard, Journ. de psychologic norm, et pathol., viii. 406.

262 PARANOIA

paranoiac delusional sj^stem might be explained, which at
first appears to be in contradiction to the susceptibility
to influence of the imaginations of youth. The playful
day-dreams of the undeveloped personality are built up in
a mobile psychic life, and when this matures and becomes
established they lose their foundation. But in paranoia
the deficiencies of intellectual functioning described continue
to exist in a personality already becoming crystallized ;
they will, therefore, produce an essentially divergent and a
more permanent effect.

Lastly, it must not be forgotten that the struggle for
existence in the complicated conditions of civilization, the
constant excitement due to the increased difficulties of Ufe,
must contribute to the peculiar character of the state which
comes into existence under the premises described. If we,
therefore, acknowledge that certain peculiarities of the
paranoiac delusional formation can be derived from circum-
scribed developmental inhibitions and on this account exhibit
points of agreement with the conduct of immature individuals
and peoples, there are yet in other directions wide-spreading
differences.

Peculiar disturbances of thought have been indicated
by Berze i as the starting-point of paranoiac delusion
formation. He thinks that in the paranoiacs there is a
disorder of apperception which makes the grasping of psychic
content in a momentary point of consciousness difficult.
From this failure of " active apperception " a feeling of
" suffering " is said to be developed which then probably
smooths the way for the development of the delusion of
persecution. The proof of these statements could scarcely
be prodiiced. On the one hand we observe that active
apperception becomes difficult or ceases altogether in
numerous morbid states, which are never, or only temporarily
accompanied by delusion formation (mania, deUrium,
paralysis, idiocy) ; on the other hand there can be no question
at all in paranoia of a general extension of the disorder
named ; the systematic development of the delusion here
definitely presupposes the firm hold of leading trains of
thought and the selective preference for definite impressions
and ideas.

Summary. — If we now summarize the discussion, it
must approximately be said that heightened self-consciousness
appears to me to be an essential foundation of paranoia.

' Berze, ijber das Primarsymptom der Paranoia. 1893.

FREQUENCY AND CAUSES 263

From it proceed the high-flying plans as well as the increased
sensitiveness to the difficulties of the struggle for existence,
which are especiall}^ great for the psychopath. At the same
time by the strong affective emphasis of the experiences
of life their personal interpretation and evaluation is
favoured. Thus the preliminary conditions are provided
for the development of ideas of grandeur and of persecution.
But that it comes to delusion formation in the paranoiac
sense rests on the insufficiency of intellectual functioning in
consequence of partial developmental inhibitions, which cause
certain primitive habits of thought to continue permanently.
Here belongs the tendency to day-dreaming, to an egocentric
view of life, and to uncritical yielding to any ideas that
occur. In accordance with this view paranoia, as is also
from cUnical points of view feasible, would be brought into
the neighbourhood of degeneration hysteria, in which we
are likewise concerned with the persistence in isolated
psychic domains of stages of development which have been
surmounted.

If we have up to now exerted ourselves to explain the
points of view from which the development of paranoia
from a peculiar predisposition might be made com-
prehensible, reasons are also not wanting which might argue
for the existence of an actual morbid process transforming
the personality from a definite point of time. Since
tangible external causes, as a rule, are not demonstrable,
maladies must be thought of which are developed from
internal causes. With regard to the indubitable relations
of paranoia to degeneration, morbid germs might come into
consideration, which were already present in the disposition,
but only later develop in an independent manner, as in
certain familial diseases of nerves, for example, Huntington's
chorea. Of significance for this question is, firstly, the
circumstance, that the roots of the paranoiac delusion can
by no means always be traced back to a distant past ; the
ideas often appear rather abruptly, at least according to
the representations of the patients. Here it must certainly
be taken into account that invariably the patients only
come under our observation many years after the commence-
ment of the maladj^ and that their statements very commonly
are more or less strongly influenced by pseudo-memories.

Further, for the assumption of a morbid process the
course in exacerbations which is seen fairly often, might
be mentioned, the crowding together of delusion formatioii

264 PARANOIA

in relatively short periods of time with intervals lasting
for years. It is evident that this argument would only
have significance if the paranoiac development of the
personality assumed above were conceived as wholly
independent of external influences. But if one acknow-
ledges, as we did, that for the coming into being of the
paranoiac delusion the struggle with life is of authoritative
significance, a course in exacerbations might very well
result from external influences. Unfortunately up to now
no adequate investigations of this question are to hand ;
they might also come into collision with almost insuperable
difficulties. It must, however, be said that in the develop-
ment of a personality, probably also from internal causes,
at^any time more rapid transformations and likewise intervals
may be interpolated ; the experiences of normal life seem to
give evidence for this.

The circumstance is very noteworthy, that the content
of the delusional ideas is sometimes extraordinarily far
removed from normal thinking. It, therefore, is at first
difficult to assume here a simple development from the
normal latitude. Some evidence for our judgment may
perhaps be got from the prison psychoses, in which we see
very similar delusions, which in certain circumstances
never again disappear, developing under the pressure of
psychic injuries. Accordingly the possibility cannot be
denied that a paranoiac delusion in spite of its senselessness
may come into being solely through unfavourable emotional
influences. Certainly we must here in all circumstances
premise a well-marked paranoiac predisposition, since we are
not concerned, as among the prisoners, with unusual fortunes
in life, but with the effect of the everyday difficulties of the
struggle for existence, which only here are felt as specially
oppressive.

We come, therefore, to the conclusion, that at present
definite evidence for the assumption of a morbid process
as the cause of paranoia cannot be found, but that we have
to reckon with morbid preliminary conditions in the form
of quite definite insufficiencies of the predisposition. In so
far points of contact with the view last discussed would be
present. Only it would not concern the continued develop-
ment of morbid germs to independent morbid processes .
reaching into the psychic life, destroying and distorting, but
the natural transformations to which a psychic malformation
is subjected under the influence of the stimuli of life.

FREQUENCY AND CAUSES 265

It would have been impossible for the Freudian doctrines
not to have taken possession of the question of paranoia.
According to the results of psycho-analysis auto-eroticism,
narcism, homo-sexuality, form the starting-point of paranoia.
The disease sets up the defensive symptom of distrust
towards others in order to overcome the unconsciously
reinforced homo-sexuality. The delusional formation is in
reaUty an attempt at cure after the catastrophe. Since
these assertions are not supported either by a clearly defined
conception of paranoia or by evidence at all acceptable,
it might be unnecessary to occupy oneself further with
them.

!■

CHAPTER VI.

DELIMITATION.

The delimitation of paranoia is not less difficult than the
search into its character. We have already in the intro-
duction mentioned the changes which the extent of the
conception of paranoia has gone through in the course of
the last decades. If dementia paranoides, the paraphrenias,
and a series of other paranoid diseases are kept apart, as
has been done here, there remain still two directions in
which there are important questions of delimitation to solve.
In one it concerns the decision whether there are curable
forms of paranoia running an abortive course. Certainly
now we shall no longer be able to agree with the view of
Westphal, who in his time regarded cases of compulsion
insanity as abortive paranoia, but it remains still to
investigate whether paranoiac delusion formation must
continue permanently in all circumstances. The French
have described " bouffees delirantes ", which they are
inclined to place in relation to paranoiac diseases, and
among ourselves also one speaks of delusion formations
in degenerates, for which according to their history of origin
a relationship with those of the paranoiacs would probably
have to be acknowledged. With reference to the assumption
made by Wernicke of an " idea of over-estimation," which
may for a longer or shorter time dominate the patient,
Friedmann has, as was mentioned above, published observa-
tions about " mild delusional forms." Here in immediate
connection with external events agitating the emotions
(disappointed hopes of marriage) , a systematized but circum-
scribed delusion appeared, namely, the delusion of respect,
which gradually faded again after two or three years without
any exact rectification ; it concerned mostly women thirty
or forty years of age. Lastly, Gaupp has mentioned cases
of educated men with " depressive-paranoid " predisposition,
in whom under the pressure of painful circumstances a
distrustful delusion of reference with a certain amount of
insight and fluctuating course insidiously developed without
leading to rigid systematization.

DELIMITATION

267

It is not easy to take up a position in relation to all
these experiences. One of the principal difficulties at
present is, in my opinion, diagnostics. I have, namely,
convinced myself that there are cases of manic-
depressive insanity, which on account of the many delusional
ideas which appear and the inconspicuous colouring of the
background of mood, may with extreme ease be taken for
abortive cases of paranoia. In spite of attention specially
directed to this point it has happened to myself till quite
recently, that I have regarded such attacks as paranoiac
exacerbations. The possibility will, therefore, always have
to be reckoned with that one or other case of paranoid
disease having a favourable course, although without acquir-
ing full morbid insight, must be interpreted in the sense
mentioned. We shall have to come back to this question.

The delusion formations of the degenerate are, so far as
is known at present, invariably of psychogenic origin and are
connected with a definite, tangible occasion, as far as they at
all exhibit a certain similarity with paranoia. In this point
they thus differ throughout from the insidious development
of paranoiac delusion formation. It appears to me, therefore,
suitable to separate them from it. But it will have to be
admitted, that there may be transitions here, according to
whether a larger or smaller role falls to the personal
peculiarity on the one hand, to the external obstacles on
the other, in the history of origin of the morbid phenomena.
Paranoia and psychogenic delusion formation may, perhaps,
be regarded as the end-links in a chain in which all possible
intervening links are represented.

From this standpoint no objection could on principle be
raised against the occurrence of " mild," psychogenic forms
of paranoia resulting in cure. It would only have to be
assumed that here a " latent " paranoia exists permanently,
which not in all circumstances, but only on special occasions
leads to delusion formation. Thus it would also be
comprehensible that the delusion formation would again
come to a standstill, when the occasion was removed or
its effects counter-blaanced. Any other event in life might
then later in a similar way cause the disease. We should
thus be concerned more with the permanent tendency to
delusion formation, with isolated attacks of delusion, not,
as in developed paranoia, with an inexorably progressive
delusional transformation of all the views of hfe in a definite
direction.

268 PARANOIA

It cannot be said at present with certainty, whether
and how far the views here developed can be brought into
agreement with cHnical experiences. In any case it appears
to me that there are predispositions, which, indeed, carry
in themselves the germ of continued development in a
paranoiac direction, but only develop it further to a
transitory and indistinct delusion formation. Mercklin
speaks of personalities which throughout their whole life
are on the way to paranoia. Even among the more pro-
nounced cases of paranoia, many are found in which the
system of delusions exhibits a less rigid and closed form
than it is customary to assume from an academic point of
view. Among the psychopaths who resort to our hospital
I have come across a certain number of personalities,
certainly not very large, whom I might call " paranoid,"
in as far as they appeared to me to exhibit essential
preliminary conditions for the development of paranoia ;
some of them even displayed the rudiments of it, yet without
an actual delusional system attaining to development. I
shall try, as far as the hmited experiences at my disposal
allow, to give- a short description of this group of paranoid
personalities.

Paranoid Personalities. — In the majority of the
patients ideas of persecution were in the foreground of the
clinical picture, probably because they most frequently
give occasion for a consultation with the alienist. The
most conspicuously common feature was the feeling of
uncertainty and of distrust towards the surroundings, which
expresses itself in the most varied forms. The patient feels
himself on every occasion unjustly treated, the object of
hostiUty, interfered with, oppressed. His own people treat
him badly ; his fellow-workmen do not like him ; they
teaze him, make remarks about him, look at him derisively
as at some one mentally unsound, laugh at him. Every-
thing presses on him ; he has to endure a martyrdom, he
complains about his " life crushed and trodden on ". A
patient spoke of " pecuniary ill-usage continued for years ",
when his guardian in consideration of his small means was
not able to satisfy all his excessive financial claims. People
want to drive him from his situation ; the foreman aims
at him. In indefinite hints he speaks of secret connections,
of the agitation of certain people. Things are not as they
ought to be ; everywhere he scents interested motives,
embezzlement, intrigues ; the wire-pullers of the injuries

DELIMITATION 269

from which he suffers are known to him, but he will not
speak out. One patient could read off the faces of people
the evil in them. The physicians whose duty it is to
examine him, give a prejudiced opinion ; the authorities
show partiality. A patient, who thought that his wife had
put the virus of gonorrhoea in the soup, asserted that the
police did not wish to have the affair investigated, because
he had no money to pay. Another complained that he had
been wrongfully declared to be mentally unsound, while
the verdict had been pronounced in favour of his mental
health. Some patients expressed ideas of jealousy ; one
patient noticed that his wife did not concern herself about
him ; she showed him by her behaviour to others " that
she was perhaps unfaithful to him." He wanted to get rid
of her, but when she was gone, he had a great longing for
her, and then when she returned, he immediately re-
commenced the old reproaches.

Such delusional ideas, which emerge sometimes on one
occasion, sometimes on another, are closely accompanied
by great emotional irritability and a discontented, dejected
mood. The patient is difficult to get on with, is fault-finding,
makes difficulties everywhere, perpetually lives at variance
with his fellow-workers, on trivial occasions falls into measure-
less excitement, scolds, blusters, and swears. He composes
long-winded documents full of complaints, threatens his wife,
ill-uses the children, applies for a divorce, speaks of shooting
the foreman. Others withdraw themselves, refuse to have
anything to do with the people round them. One patient
communicated with his wife in writing only ; another
obstinately refused to obey judicial summons.

The patients have no understanding for the insufficiencies
of their personality, which appear in their whole conduct.
They are impatient and obstinate, think that they are
perfectly within their rights, that their unusual actions are
quite in order, hold firmly and stubbornly to their ideas.
On the other hand they are often extremely credulous in
regard to communications, which lie in the direction of
their thoughts ; they accept without hesitation every piece
of gossip as truth, let themselves be imposed upon, get into
scrapes.

As a rule, heightened self-consciousness can be easily
demonstrated. The patients boast of their performances,
consider themselves superior to their surroundings, make,
special claims, lay the blame for their failures solely on

270 PARANOIA

external hindrances, without which they would undoubtedly
have been in a position "to do useful and beneficial work ".
I have also come across a few cases which might be regarded
as in the initial stages of the paranoiac delusion of grandeur
in its various forms. I saw some inventors who occupied
themselves with perpetual motion, and hoped by their future
successes to gain money and honour on a considerable scale ;
one of them expected great things from savings-bank stamps
with business advertisements. Other patients were con-
spicuous by their high-flying plans and ideas for benefitting
the world, which were quite out of proportion to their
knowledge and abihty. They thought of themselves as
having a mission which they had to fulfil, although they
were not able to meet the most commonplace claims of life.
I have also met indications of erotic delusion, patients, who
in spite of the most unequivocal refusal, yet ever again
pursued the supposed beloved and tried by entreaties and
threats to make her yield.

Intellectual endowment was on the average fairly good
in the patients discussed here ; all the more striking was
the failure of judgment in regard to their delusional ideas.
Capricious behaviour with frequent change of mood was
often observed, the influence of which could also be
recognized in a restless, adventurous conducf of life.
Occasionally there were hypochondriacal complaints, twinges
of pain in the back, constriction in the breast. Several times
great sexual excitability was reported. Some patients made
suicidal attempts, occasionallj^ repeated. In isolated cases
hysterical disorders appeared, convulsive weeping, fainting
fits, diminution of the pharyngeal reflex, concentric re-
striction of the field of vision. Many patients at times took
excessive alcohol. Almost all lived permanently in freedom,
mostly without any special difficulty ; they were only on
some special occasion once in a while brought temporarily
to the hospital.

What distinguished the delusions of these patients from
those of pronounced paranoia was their vagueness and the
absence of systematic working up. Their fears and hopes
were of a more indefinite kind, were brought forward as
indications and conjectures, or they consisted in a strong
personal valuation of actual events, which was not too far
removed from the one-sidedness of normal individuals.
As far as could be known, no internal connection of the
individual component parts of the delusion with a paranoiac

DELIMITATION 271

view of life had taken place. They did not appear to have
actually passed into the flesh and blood of the patients ;
they appeared and receded again, yet without quite
vanishing. It may naturally be objected that the patients,
perhaps, kept their innermost trains of thought secret, or
that the development of a delusional system will still take
place later. Further experience must decide about these
possibilities. At present the assumption appears to me
to be well founded, that cases of undeveloped, " rudi-
mentary " paranoia would not only fit in with our view of
the character of the disease, but also come actually under
observation.

It will certainly be often doubtful in the individual case
whether and when we are right in calling a morbid
personality, in the sense here delimited, " paranoid." It
seems to me to be essentially a combination of uncertainty
with excessive valuation of self, which leads to the patient
being forced into hostile opposition to the influences of the
struggle for life and his seeking to withdraw himself from
them by inward exaltation. Further, a strong personal
colouring of thought by vivid feeling-tones, activity of the
power of imagination and self-confidence, might be of
significance. If these peculiarities lead to isolated or general
delusions without systematization, the paranoid psychopath
would with that be approximately characterized.

The great restriction which the conception of paranoia
has suffered in the course of the last few decades, frequently
led to the prophecy, that it would soon wholly disappear.
Indeed, Specht has made the attempt to solve the whole
morbid state of paranoia. He thought that querulant
delusion first, but then next paranoia contained in itself
" the whole inventory of mania," the pressure of talk and
writing, the restlessness, the digression, the readiness of
repartee. For him accordingly the disease only signifies
the reaction of a manic-depressive predisposition to an event
which excites emotion. It must be admitted that some of
the features mentioned are now and then found in paranoiacs,
further, that there are manic patients with abundant
delusions mentally worked up, who on account of the slight-
ness of their excitement may for a considerable time be
held to be paranoiacs. On the other hand the view of
Specht appears to me to shoot far beyond the mark. There
are numerous paranoiacs in whom the peculiarities
resembling those of manic patients are altogether absent*.

272 PARANOIA

But when they are present, they invariably have a history
of origin and a significance quite different from the similar
manic phenomena. Pressure of speech and writing are
explained by the active endeavour to defend themselves
against persecution or to advance their ovm high claims,
restlessness by the incapacity for persevering, useful work
in consequence of the delusional disorders, digression by
the heightened activity of the power of imagination,
readiness of repartee by increased self-consciousness and
by the mental working up of the content of the delusions,
which has long ago solved all difficulties, although often in
an extremely inadequate manner.

CHAPTER VII.

DIAGNOSIS AND TREATMENT.

The diagnosis of paranoia presents scarcely any difficulties
to attentive consideration of the slow development, of the
peculiar, connected delusion formation, of the excellent
preservation of intelligence as well as order in the train
of thought, in conduct, and in activity. Certainly there
are a number of diseases which may temporarily exhibit a
similar picture. The delimitation of the malady from the
" paranoid " mental disorders we have already considered.
That there can be no question of transitions between
paranoia in the sense here delimited and dementia praecox,
as has been assumed by some observers, needs no special
discussion.

Schizophrenia. — On the other hand at this point the
possibility mtr5t""5hortly be discussed, that many cases of
apparent paranoia might really be imperfectly developed
schizophrenias. In the individual case it is not always
easy to decide this question. The delusional system of
the paranoiac is internally more closed, more rounded off,
more thought out ; it takes account up to a certain degree
of objections, tries to explain difficulties, in contrast to
the abrupt delusional ideas of the paranoid schizophrenics^
which are often contradictory to eaih otheF and also changer
frequently. / In thFlatter, moreover, the signs oFemotionar'
'3evastati6ii" will not be missed, the slight internal interest
not only in the surroundings, but also in the delusion,
which at most leads to occasional outbursts, but provides
no permanent motives for activity. In the paranoiac also
we meet now and then a reserved, repellent manner, and
peculiarities of many kinds in the conduct of life. But
his conduct is invariably far more grounded on deliberation
or emotional processes than the impulsive pecuHarities of
^he schizophrertic. The whole personality in spite of its^
morbid features appears more comprehensible, more natural,
more susceptible to influence. It is much easier by
intelligent treatment to come into inner relations with it
than with the capricious, inaccessible schizophrenic.

274 PARANOIA

Schneider has described a case, which I consider a genuine
paranoia, as a paranoid terminal state of dementia praecox,
as I behevc, without sufficient foundation.

Paraphrenia. ' — We have further still to discuss the dis-
tinction of paranoia from the paraphrenic diseases, especially
from the systematic form. In the first periods of the malady
the similarity of the clinical states is so great that it will
be very difficult to keep them separate. The circumstance
seems to me to be of significance, that in paranoia exalted
self-consciousness appears more distinctly from the outset ;
if the delusion of grandeur dominates the morbid state
from the beginning or at least very soon, it is probably
a case of paranoia. With this difference the fact is, perhaps,
also connected, that the paranoiac is usually not nearly
so much tormented by his ideas of persecution, and also
not so much influenced in his actions as the paraphrenic
patient. The latter proceeds far more regardlessly against
his supposed persecutors, soon has resource to self-help
and with all means in his power, so that invariably he comes
to the institution comparatively early and often has even
to be kept there permanently. At the same time he carries
on the struggle with the greatest acrimony. In contrast
to that the paranoiac possesses far more self-control, restricts
himself to legal methods of fighting, yields to obvious
supremacy, and understands how to avoid permanent
deprivation of freedom by circumspect behaviour and
concession. The compulsion of the morbid change by
no means subjugates the personality to the same extent
as in paraphrenia. Moreover, we have before us in the
latter disease a constantly, although slowly progressive
course, while the paranoiac may exhibit for decades a fairJN
uniform state, and often learns also to come to an agreement,
practically endurable, with the difficulties resulting from
his delusion. Besides that the delusion in paraphrenia
gradually becomes alwaj's more extraordinary ; hallucina-
tions and exuberant ideas of grandeur are added, and the
patients in their whole conduct are seen to be so strongly
dominated by the morbid phenomena that they now can
scarcely any longer be confused with the orderly and
sociable paranoiacs who mostly are even able to earn their
living.

Many cases of the " delire d'imagination " or " retro-
spectif," which by the French are taken together with

' Dementia Preecox and Paraphrenia, p. 283.

DIAGNOSIS AND TREATMENT 275

" delire d'interpretation," our paranoia, probably belong
to confabulating paraphrenia. In it the extraordinary
abundance of pseudo-memories is noteworthy ; they serve
by no means only for the development of a definite delusion
as in paranoia, but they bring to light all possible trifles
frequently of no importance at all. The delusional inter-
pretation, conjectures, and presentiments which are always
in the foreground in paranoia and are only supplemented
and confirmed by pseudo-memories, go quite into the back-
ground here behind the regardless confabulation. The
development of the malady is usually accomplished with
considerably more rapidity than in paranoia ; at the same
time the indications of psychic weakness, striking lack of
judgment, emotional dulness, incoherence, for the most
part appear fairly soon in an unmistakable manner.

Manic-Depressive Insanity. — Essential difficulties may,
as Liihr 1 among others has shown, occasionally arise
in distinguishing paranoia from delusional states of manic-
depressive insanity, as just attacks of that kind occasionally
exhibit a very " extended " course and comparatively few
conspicuous emotional disorders. To this there may be
added discharge by an external occasion, alternation or
mixture of morbid phenomena of various kinds and tardy
recovery without genuine insight. As to detail, it must be
remarked that in the forms with depressive colouring more
exact observation can still distinctly recognize the per-
manently depressed or anxious mood, which characterizes
states of that kind. In contrast to that the paranoiac
appears in general less constrained emotionally ; he only
becomes irritated and embittered, when he is telling of
the wrongs done to him. Abrupt fluctuations of mood,
especially a sudden outburst of jocularity, pleasure in
enterprise, indications of flight of ideas, likewise the appear-
ance of ideas of sin, hopelessness, despair, give evidence for
manic-depressive insanit}^

Hypomania. — In hypomanic patients one will have
specially to take into account their volitional restlessness,
which is ever going after new plans in contrast to the steady,
uniform pursuit of a definite aim by the paranoiac. Further,
the demonstration of heightened distractibility and suscepti-
bility to influence from the surroundings is of significance.
The delusion formation mostly betrays a playful, bragging
character, and also probably changes its content, while the

^ Lahr, Schweizerhof, 3, Bericht, 59, 1903.

276 PARANOIA

paranoiac, true to his convictions, liolds fast to the same
ideas once they are developed. Lastly, the manic mood
inclining to outbursts of anger or to self-derision is
characteristic, and essentially different from the dignified
reserve or the naive confidence of the paranoiac.

For the assumption of manic-depressiye insanity, in-
dependent of the colouring of the actual cUnical picture,
the fact that other attacks with a favourable course have
preceded is of great weight. On the other hand the absence
of other attacks before and after cannot be made use of
for the diagnosis of paranoia, even when the history of the
patient is followed, as Thomsen has done, for many years.
We have, indeed, already seen that the free intervals in
manic-depressive insanity may extend over three or four
decades, but above all that well-characterized cases with
only one attack in a lifetime are by no means rarities. That
is also the reason, why I, with Kleist, must very decidedly
call in question the cured " acute " forms of paranoia, in
so far as they do not come under the heading of " abortive "
paranoia described above.

Liars and Swindlers. — With the paranoid person-
aUties, so far as they exhibit ideas of grandeur, morbid
hars and swindlers may have a certain external similarity.
Only in the latter it concerns not genuine delusions, but
" delusional imaginations ", sudden fancies, which are brought
forward more in a playful manner, and come and go without
acquiring any authoritative influence on the internal aspect
of the personahty. The content of these inventions is
usually far more variegated and extraordinary than the
monotonous delusions of the paranoiac, which conform more
to the actual circumstances of life. With regard to the
wrongful claimants to thrones, claimants to money, and
benefactors of the people, the question will occasionally
emerge, how far it concerns paranoiacs or conscious swindlers.
The circumstance is here decisive, whether the individuals in
question themselves beUeve in the justice of their claims or
in their mission. It can usually be ascertained by somewhat
long observation whether they utilize their proceedings solely
for the attainment of selfish ends, or whether the matter
itself really lies next their heart, whether they also hold fast
to it when they get nothing but suffering from it.

Treatment — There can be no question of real treat-
ment of the paranoiac in the nature of the case. Of course,
one may hope that a life without any specially strong

DIAGNOSIS AND TREATMENT 277

emotional stresses or strains, protected from excesses, and
filled with well-regulated activity, may contribute to prevent
the development of the slumbering paranoiac germs, and
make exacerbations of the malady, which might appear,
nm an abortive course. The cure of a pronounced paranoia
by direct psychic influence could probably be expected
only by a psycho-analyst. Bjerre has published a case
of that kind, in which he, certainly without actual psycho-
analysis, but by a kind of cautious art of persuasion, cured
a delusion of persecution which had existed more than a
decade. Unfortunately the diagnosis of paranoia admits
of grave doubts. Thus we shall in the meantime have to
restrict ourselves to keeping our patients by distraction
and occupation as much as possible from being absorbed
in their delusional ideas. That frequently succeeds, in
favourable circumstances for decades, so well, that the
patients in spite of the most marked delusions are yet
capable of living without too great difficulty in freedom.
Every effort will, therefore, be made to save them, as far
as it can at all be done, from seclusion in an institution.

INDEX

MANIC-DEPRESSIVE INSANITY

Acute delirious mania, hi.

Acute mania, 27, 61.

Age, 40, 167.

Alcoholism in parents, 165.

Alcoholism in patients, 178.

Amentia (confusional or delirious

insanity), igg.
Anxious excitement, 30
Anxious mania, 103.
Appetite, 44.

Approach of fresh attack, 1 50.
Arteriosclerosis, 50, 163, 198.
Association experiments, 15, 17,

156.
Blood, 49.
Blood-pressure, 50.
Blood-serum, 49.
Bodily illnesses, 179.
Bodily symptoms, 44.
Body-weight, 45, 158.
Brain disease, gross, 178.
Busyness, 57.

Capacity for work, 57.

Causes, 165.

Cerebral syphilis, 198.

Cholaemia, 49.

Chronic mania, 161.

Chronic melancholia, 161.

" Circularisme visceral," 192.

Circulation, 50.

Classification, 3.

Classification of fundamental states,

118.
Confinement, 179.
Consciousness, 7. 93,
Constitutional excitement, 125.
Conversation, 33.
Course, 139

Course of states of depression, 97.
Course of manic attacks, 72.
Course of mixed states, 115.
Cyclothymic temperament, 131.

Death, 164.
Definition, i.
Delimitation, 185.
Delirious mania, 70.
Delirious melancholia, 95.
Delusional insanity, 194.
Delusional mania, 68.
Delusions, 19, et seq. 62, 68, 90, 9.5.
Pffmirntia prffrn-f, T"7?
Depersonalisation, 75.
Depression with flight of ideas, 107.
Depressive mania, 103.
Depressive states, 75.
Depressive temperament, 118.
Dermography, 50.

Development of psychic personality'
170.

Development, Period of, 167.

Diabetes insipidus, 49.

Diagnosis, 195.

Discharge of volitional resolves, 38.

Distrartibility, 6.

Duration of individual attacks, 136.

Duration of manic attacks, 73.

Duration of states of depression, 97.

Echo-phenomena, 36.

Epileptic attacks, 53.

Ergograph, 36.

Exaggerated opinion of self, 55.

Excitability, 28.

Excited depression, 104.

Excitement, Constitutional \i^.

Exophthalmos, 50.

External behaviour, 58.

External influences, 177.

Fantastic melancholia, 89.

Feeling of fatigue, 30.

Feeling of guilt, 120.

Feeling of insufficiency, 37.

Flight of ideas, 14.

Free intervals, 137.

Frequency of individuals forms, 133.

Fresh attack, .\pproach of. 150

Fundamental states, 117

General course, 133.
General paralysis, 197.
Glycosuria, 48.
Gross brain disease, 178.
GrumbHng mania, iii.

Hair, 48.

Hallucinations, 8, 68, 89, 9.5-
Hand-writing, 34.
Head injuries, 179.
Hereditary taint, 165.
Hypochondriacal ideas, 92.
Hypomania, 54.
Hysterical disorders, 52.
Hysterical states. i99-

Ideas of annihilation, <>3.
Inherited syphilis, 167.
Inhibited mania, 109.
Inhibition, 15, 36.
Inhibition and facilitation. Relate 1

phenomena, 42.
Insight, 21, 55, 78, 149.
Intestinal disorders, 49.
Involution, Period of, 168.
Irritable temperament, 130.

Java, Natives of, 170.

Linguistic expression, 114.

Mania, Anxious, 103.
Mania, Chronic, 161.
Mania, Depressive, 103.

278

INDEX

279

Mania, Inhibited, 109.

Mania mitis, 54.

Mania with poverty of thought,

104.
Manic states, 54.
Manic stupor, 106.
Manic temperament, 125.
MelanchoUa, Chronic, 161.
Melancholia, Fantastic, 89.
Melancholia gravis, 80.
Melancholia, Paranoid, 85.
Melancholia, Periodic, 186.
Melancholia simplex, 75.
Memory, 55.

Mental disease in parents, 165.
Mental efficiency, 17.
Menses, 48, 52.
Metabolism, 48.

Mixture of fundamental states, 130.
Mixed states, 39, 42, 99.
Moral insanity, 196.
Morbid anatomy, 164.
Movements of expression, 38, 60, 65.
Multiplicity of clinical pictures, 114.

Nails, 48.

Natives of Java, 170.
Nature of the disease, 181.
Nervous complaints, 123.
Nervous disorders, 52.
" Nervous dyspepsia," 45.
Neurasthenia, Periodic, 192.

Organic disorders, 53.

Paranoia, Periodic, 192.
Paranoid melancholia 85.
Partial inhibition and exaltation

109.
Perception, 5, 6.
Perception experiments, 5, 157.
Periodic melancholia, 186.
Periodic neurasthenia, 192.
Periodic paranoia, 192.
Period of development, 167.
Period of involution, 168.
Personal idiosyncrasy, 177.
Physical degeneration, 167.
Pressure in writing, 40.
Pressure of activity, 26, 57.
Pressure of speech, 31.
Pregnancy, 179.
Prognosis, 159.

Progressive manic constitution, 129.
Pseudo-melancholia, 113.

Pseudo-memories, 8.
Psychic decline, 161 et seq.
Psychic influences as cause, 179.
Psychic symptoms, 5.
Psychogenic states, 199.
Pupils, 52.
Pulse-rate, 50.

Querulants, 196.

Rascals, 196.

Rationalisation by patients, 60.
Relation between attacks and in-
tervals, 137.
Respiration, 52.
Restriction of activity, 38.
Retention, 8.
Rudiments of the disease, 118.

Self-confidence, 122.

Self -consciousness, 58.

Self, Exaggerated opinion of, 55.

Sentimentality, 121.

Sex, 174.

Sexual excitability, 22, 59, 120.

Skin, 48.

Sleep, 44.

Speech, 38.

Spelling, 39.

Stupor, 37, 79.

Suicide, 25, 38, 87, 123, 130, 164,

165, 205.
Swindlers, 196.
Syphilis, 178.
Syphilis, Cerebral, 198.
Syphilis, Inherited, 167.

Tears, Secretion of, 48,

Temperament, Cyclothymic, 131.

Temperament, Depressive, 118

Temperament, Irritable, 130.

Temperament, Manic, 125.

Temperature, 52.

Tendon reflexes, 52.

Thyroid gland, 50.

Train of ideas, 13.

Transition states, 99 et seq., 150.

Treatment, 202.

Urine, 48.

Waxy flexibility, 36.
Weakmindedness, 200.
Weak sentimentality, 121.
Weather, Influence of, 52.
Writing, 39, 66.
Writings, 34.

PARANOIA

Age, 254.
Appetite, 224.

Bodily symptoms, 224.

Causes, 253.

Claimants to thrones, 238, 253.

Clinical forms, 225.

Compensation, Psychological, 259.

Conduct, 223.

Course, 250.

Cures, Self-invented, 224.

Defensive measure, 259.
Definition, 212.

28o

INDEX

Degeneration, 255, 263.

Degeneration hysteria, 263.

Delimitation, 266.

Delusion formations of the de-
generate, 267.

Delusion of respect, 266.

Delusion of grandeur, 270.

Delusions of grandeur, Eroticism,
■245. 270.

Delusions of grandeur. High descent,

235-

Delusions of grandeur. Inventors,
232, 270.

Delusions of grandeur. Prophets
and saints, 238, 270.

Delusions of jealousy, 229.

Delusions of persecution, 225.

Delusions of reference, 217.

Depressive- paranoid predisposition,
266.

Developmental inhibitions, 261, 263.

Diagnosis, 273.

Distortion of psychic picture, 261.

Dreamy hallucinations, 248.

Delusion, Residual, 251.

Dreaming, Self-complacent, 25Q.

Duration up to admission to hos-
pital, 253.

Ecstatic states, 241, 251.
Egocentric trend of thought, 260.
Exalted self-consciousness, 228, 231,

245, 258, 262, 269.
Emotional irritability, 269.
Emotional tensions, 260.
External occasions, 255.

Forebodings, 220.

Formation of sects, 243.

Founders of communities, 243.

French views, 213.

Frequency, 253.

Frequency of individual forms, 249.

Freudian doctrines, 265.

General morbid symptoms, 215.

Hallucinations, 215, 248.

Heredity, 254.

Hypochondriacal complaints, 224,'

228, 232, 270.
Hypomania, 275.

Ideas of exaltation, 220.

Ideas of injury, 220.

Ideas of jealousy, 228.

Ideas of persecution, 268.

Infantile features ia thinking, 261.

Insufficiency of intellectual function-
ing, 263.

Insufficiency of personality, 269.

Insufficient outward recognition,
256.

Internal causes, 255, 263.

Introduction, 207.

Issue, 251.
Liars, 276.
Manic-depressive insam i

275-
Manic-depressive predisposition,

271-
Manic phenomena, 272.
Memory, 216.

Mental disorder. Dominating, 220.
Mood, 222, 228, 269.
Morbid process, 263 et seq.
Mystics, 238.
Mj'thomanics, 214.

Over-estimation of self, 233, 271 .

Paranoia, Abortive, 222, 266.

Paranoia, Acute, 208.

Paranoia, Idiopathic, 254.

Paranoia, Latent, 267.

Paranoia, Periodic, 208.

Paranoia, Rudimentary, 271.

Paranoiac germs, 255.

Paranoiac personality, 252.

Paranoid personalities, 268.

Paraphrenia, 274.

Partial developmental inhibitions,

263.
Personal pecuharity, 225, 255 et seq.
Predisposition, Psychopathic, 25.)
Prison psychoses, 257.
Pseudo-memories, 216, 220, 221,

230, 236. 239, 240, 247, 251, 254.
Psycho-analysis, 277.
Psychogenic forms, 267.
Psychological compensation, 250
Psychopathic predisposition, 25^

Religious foundations, 243.
Resistance, 238.
Retention, 216.

Schizophrenia, 273.
Self-complacent dreaming, 259.
Self-consciousness, High tension of,

256.
Sex, 253.
Sleep, 224.

Struggle for existence, 262, 264.
Suicide, 224.
Superstition, 210.
Symptoms, 215.

Systematization, 208 et seq., 221.
Swindlers, 276.

Tendency to delusion formation,

267.
. Treatment, 276.

Undeveloped thinking, 260 et seq.
Unsymmetrical development, 261.

Verrucktheit, 207 et seq.
Visionary exjieriences, 215, 238, 251.

Weakmindedness, 252.

2690

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